Evaluation of Provider Adherence to Antibiotic Selection Following the Implementation of Antimicrobial Stewardship Committee Recommendations for the Empiric Treatment of Hospitalized Adults with Urinary Tract Infections
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oregon; portland; psvmc
Pharmacy and Pharmaceutical Sciences
• Urinary tract infections (UTIs) are one of the most common indications for prescribing antibiotics in the inpatient setting. • Recent literature suggests that not all patients are prescribed empiric antibiotics that are adherent to Infectious Diseases Society of America (IDSA) guidelines. • Arguably the most positive, predictable impact on provider adherence to guideline-based treatment regimens is achieved when evidence-based recommendations are made easily accessible. • The causative organism at the time of diagnosis and initiation of antibiotic therapy for a UTI is generally unknown: patients are often prescribed broad-spectrum therapy that may be unnecessary. • Inappropriate treatment of infections has been shown to be an important determinant of the development of antimicrobial resistance, hospital mortality, prolonged hospitalization, increased adverse antibiotic effects and increased healthcare costs. • The IDSA guidelines emphasize the importance of using antibiotics to target E. Coli, which is the organism responsible for ~75% of UTIs, and tailoring empiric antibiotic selection based on local susceptibility data. • Susceptibility data from 2019 in the POR demonstrates that the E. coli resistance rates to sulfamethoxazole-trimethoprim and ciprofloxacin are 19% and 14%, respectively. • On July 1, 2019, the Providence Oregon Region (POR) Antimicrobial Stewardship (AMS) Committee gained P&T approval for the release of regional, preferred empiric antibiotic recommendations for hospitalized adults with common infections, including UTIs. • The susceptibility rate of E. coli to ceftriaxone in the POR is 94%, making it the preferred, empiric intravenous (IV) agent.
• The purpose of this study is to assess the rate of POR provider compliance to empiric, regional guidelines before and after the implementation of the AMS Committee treatment recommendations for UTIs, and evaluate the intervention’s financial impact.
Describe the clinical and financial impact of a regional AMS intervention on provider adherence to empiric antibiotic recommendations for adult patients hospitalized with a urinary tract infection
Institutional Review Board (IRB)-approved • Multi-center, pre- and post-intervention, observational, retrospective review, spanning 12 months, of hospitalized adults admitted to any one of the eight POR hospitals who received IV antibiotics for a UTI • Pre-Group (Control): • January 1, 2019—June 30, 2019 • Post-Group: • July 1, 2019—December 31, 2019 • Inclusion Criteria: • Age ≥ 18yo, hospitalized, received IV antibiotics for the indication of a UTI • Exclusion Criteria: • Age < 18yo, any bacteremia, concomitant infection at a different anatomical site • Primary Outcome: • Rate of empiric IV ceftriaxone usage (based on administrations) compared to IV antipseudomonal agents, pre- vs. post-AMS antibiotic recommendation implementation • Secondary Outcomes: • Average length of hospital stay (LOS) • 30- and 90-day mortality (Providence patients) • Days of therapy (DOT) per 1000 patient days • Cost Analysis: • Cost-savings impact for length of hospital stay • Cost-savings impact for total cost of antibiotic by days of therapy
Patient Population • The total number of patients included was 5,435 and the total number of empiric IV antibiotic administrations was 6,504. • There were more patients and empiric IV antibiotic administrations in the Post-Group than in the Pre-Group (2733 vs. 2702 and 3401 vs. 3103, respectively). • At baseline, patients were similar in age, gender, race, ethnicity and hospital disposition (ICU vs Non-ICU) between the two groups. • Mean age was 66.1 years in the Pre-Group and 65.6 years in the Post-Group. • The average Charlson Comorbidity Index (CCI) Score was similar between the two groups (4.85 in the Pre-Group and 4.71 in the Post-Group). • Hospital location for empiric IV antibiotic administration was similar between the two groups. • The predominant indication for antibiotic use was for UTI— Lower. Outcomes • The rate of empiric IV ceftriaxone administrations for UTIs, compared to other IV anti-pseudomonal agents, increased in the Post-Group compared to Pre-Group (87.0% vs. 84.7%, respectively). • The usage rate (based on administrations) of almost all empiric IV anti-pseudomonal agents was decreased in the Post-Group. • The average length of hospital stay (excluding patients with LOS <1 day) was reduced in the Post-Group compared to the Pre- Group (6.05 days vs. 6.85 days, respectively). • Both 30-day and 90-day mortality were reduced in the Post- Group. • The DOT/1000PD in the Post-Group increased for ceftriaxone and decreased for Zosyn. • The total cost of LOS per patient was reduced in the Post-Group by $3.9 million compared to the Pre-Group ($63.5 million vs. $67.4 million). • The average cost of LOS per patient was reduced by $4,511 in the Post-Group compared to the Pre-Group ($28,865 vs. $33,376). • There was a total cost-savings, with regard to cost of antibiotic by DOT, in the Post-Group. Study Limitations • Retrospective, non-randomized study • Statistical analysis of this study is currently pending • Data pulled and analyzed based on antibiotic indication • Study did not include assessment of patient outcomes: • Treatment failure • Clinical cure • Inconsistencies for electronic medical record documentation of mortality • Unmeasured, confounding variables could have influenced the result of physician adherence to guideline-based treatment recommendations
• We demonstrated that a simple AMS intervention involving the dissemination of region-specific empiric treatment recommendations was associated with an improvement in provider adherence to IDSA guidelines. • The AMS initiative also showed a reduction in unnecessary broadspectrum antibiotic and fluoroquinolone use for UTIs. • We found that the average length of hospital stay was markedly reduced, following the intervention, which resulted in approximately $3.9M in cost savings for the POR.
Graduate Medical Education
Conference / Event Name
Academic Achievement Day, 2021
Providence St. Vincent Medical Center
Watkins, James E.; Christensen, Alyssa B; and Footer, Brent, "Evaluation of Provider Adherence to Antibiotic Selection Following the Implementation of Antimicrobial Stewardship Committee Recommendations for the Empiric Treatment of Hospitalized Adults with Urinary Tract Infections" (2021). Providence Pharmacy PGY1 Program at Providence Portland and Providence St. Vincent Medical Centers 2021. 3.