Are Antibiotic Stewardship Strategies in Community Hospitals Feasible?

Prospective audit allows antibiotic stewards to engage the prescribing clinician after the antibiotic has been used, typically after two or three days, to optimize antibiotic treatments.
Prospective audit allows antibiotic stewards to engage the prescribing clinician after the antibiotic has been used, typically after two or three days, to optimize antibiotic treatments.

According to results published in JAMA Network Open of a study that tested the feasibility and results of 2 antimicrobial stewardship and intervention strategies, only post-prescription audit and review (PPR) was both feasible and effective in settings with limited resources.

The strategies tested targeted vancomycin hydrochloride, piperacillin-tazobactam, and the antipseudomonal carbapenems. The strategies identified were (1) modified preauthorization, in which the prescriber needed approval from a pharmacist for continued use of the antibiotic after the first dose; and (2) PPR, in which the pharmacist engaged the prescriber about antibiotic appropriateness after 72 hours of therapy. The 3-stage, multicenter, prospective non-randomized clinical trial with crossover design ( NCT02212808) was performed at 4 community hospitals in North Carolina. The study patients were receiving targeted study antibacterial agents or alternative non-study antibacterial agents.

A total of 2692 patients participated in the study and pharmacists performed 1456 modified preauthorization interventions (median, 350; range, 129-628) and 1236 PPR interventions (median, 298; range, 273-366). Strict preauthorization was deemed not feasible during discussions of intervention approval; therefore, a modified preauthorization process was used. In the study, 2 hospitals performed modified preauthorization for 6 months, then PPR for 6 months after a 1-month washout period. The other 2 hospitals performed the study with these methods reversed.

During the PPR period, study antimicrobials were deemed inappropriate twice as often (41.0% vs 20.4%; P <.001). During modified preauthorization, pharmacists recommended dose change more often (15.9% vs 9.6%; P <.001).  Pharmacists also recommended de-escalation during PPR more often (29.1% vs 13.0%; P <.001). Overall, antibiotic use also decreased during PPR when compared with historic controls (mean days of therapy per 1000 patient-days, 925.2 vs 965.3; mean difference, −40.1; 95% CI, −71.7 to −8.6). This did not occur during preauthorization (mean days of therapy per 1000 patient-days, 931.0 vs 926.6; mean difference, 4.4; 95% CI, −55.8 to 64.7).

The study results had limited generalizability because the 4 centers were all located in the same state, received support to participate in the study, and were interested in participating. The study was also designed to test feasibility and was therefore underpowered to evaluate the results of these interventions on antimicrobial use. An unexpected shortage of piperacillin-tazobactam also occurred during the study, which limited the ability to measure outcomes at 1 hospital. Survey data also suffered from moderate response rates from clinicians and potential recall biases. Further, because pharmacists performed intervention and data collection activities with no second-level reviews to determine appropriateness, it is possible that appropriateness of data may be biased by individual pharmacist’s perceptions.

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According to the investigators, this data, “add[s] to the growing literature that stewardship can be successfully performed in community hospital settings.” The interventions produced more interactions between pharmacists and prescribers, which means there are more chances to optimize therapy. The investigators believe that in order for hospitals to be most efficient, “stewardship teams in community hospitals will need to have dedicated time and resources to complete stewardship interventions that fit their local environment.”


Anderson DJ, Watson S, Moehring RW, et al. Feasibility of core antimicrobial stewardship interventions in community hospitals. JAMA Netw Open. 2019;2:e199369.