Practical efforts to curb antibiotic prescriptions could have large effect in small hospitals

An ARLG study sheds light on the feasibility of antibiotic stewardship programs in small, community hospitals that have limited resources.

The DICON I study refers to the Duke Infection CONtrol Network that provides access to the community hospitals doing research. Led by Deverick Anderson, M.D., director of the Duke Center for Antimicrobial Stewardship and Infection Prevention, the study included four community hospitals in North Carolina. The results published in JAMA Network Open demonstrated an approach that could be expanded to the nation’s wider network of small hospitals, where more than half of the U.S. population accesses care.

“This is a matter of major consequence, because up to 50 percent of antibiotic use in our study was inappropriate, meaning there was a better choice or the prescription was simply unnecessary,” said Anderson.

Anderson and colleagues partnered with the community hospitals in North Carolina to explore how best to perform active, CDC-recommended stewardship interventions using existing hospital resources.

“We have to develop systems that are scalable and effective in helping reduce the improper or needless use of antibiotics at every level,” Anderson said, noting that overuse of these critical drugs has led to the spread of deadly superbugs that are resistant to previously effective treatments.

Two strategies were tested using hospital pharmacists as designated stewards. In one strategy, pharmacists were enlisted as the gatekeepers for antibiotic use, giving pre-approval to doctors before the drugs could be prescribed to patients.

The pre-approval aspect was quickly determined to be too difficult, because doctors wanted the flexibility and autonomy to manage their patients. Instead, a modified approach was adopted, in which doctors could prescribe the first dose of antibiotic, but that was followed by a pharmacist review.

The second tested strategy involved a post-prescription audit, where pharmacists reviewed the effectiveness of the antibiotic to determine whether it should be continued or changed after the patient received the antibiotic for three days.

All four hospitals participated in both interventions for six months, covering a total of nearly 2,700 patients.

The study found that pharmacists at the four participating hospitals performed 1,456 modified prescription approvals and 1,236 post-prescription audits. Study antimicrobials were determined to be inappropriate two-times as often under the post-prescription audit strategy compared to the modified pre-approval strategy.

Overall antibiotic utilization decreased under the audit system compared to historical controls, but the modified prescription authorization intervention did not reduce the use of antibiotics.

“Even modest decreases in antimicrobial utilization are valuable, particularly when potentially achievable in the more than 3,000 community hospitals in the U.S.,” Anderson said. “This study suggests there are approaches that can work, even in hospitals where resources might be limited.”

In addition to Anderson, study authors include Shera Watson, Rebekah W. Moehring, Lauren Komarow, Matthew Finnemeyer, Rebekka M. Arias, Jacqueline Huvane, Carol Bova Hill, Nancie Deckard and Daniel J. Sexton, along with the Antibacterial Resistance Leadership Group.

The study received support from the Antibacterial Resistance Leadership Group supported by the National Institute of Allergy and Infectious Diseases, which is part of the National Institutes of Health (UM1AI104681).

Note: Content for this article originally appeared in an announcement on Duke Health.