Abstract
To assess the effectiveness and acceptability of antimicrobial stewardship-focused implementation strategies on inpatient fluoroquinolones. Stewardship champions at 15 hospitals were surveyed regarding the use and acceptability of strategies to improve fluoroquinolone prescribing. Antibiotic days of therapy (DOT) per 1,000 days present (DP) for sites with and without prospective audit and feedback (PAF) and/or prior approval were compared. Among all of the sites, 60% had PAF or prior approval implemented for fluoroquinolones. Compared to sites using neither strategy (64.2 ± 34.4 DOT/DP), fluoroquinolone prescribing rates were lower for sites that employed PAF and/or prior approval (35.5 ± 9.8; P = .03) and decreased from 2017 to 2018 (P < .001). This decrease occurred without an increase in advanced-generation cephalosporins. Total antibiotic rates were 13% lower for sites with PAF and/or prior approval, but this difference did not reach statistical significance (P = .20). Sites reporting that PAF and/or prior approval were "completely" accepted had lower fluoroquinolone rates than sites where it was "moderately" accepted (34.2 ± 5.7 vs 48.7 ± 4.5; P < .01). Sites reported that clinical pathways and/or local guidelines (93%), prior approval (93%), and order forms (80%) "would" or "may" be effective in improving fluoroquinolone use. Although most sites (73%) indicated that requiring infectious disease consults would or may be effective in improving fluoroquinolones, 87% perceived implementation to be difficult. PAF and prior approval implementation strategies focused on fluoroquinolones were associated with significantly lower fluoroquinolone prescribing rates and nonsignificant decreases in total antibiotic use, suggesting limited evidence for class substitution. The association of acceptability of strategies with lower rates highlights the importance of culture. These results may indicate increased acceptability of implementation strategies and/or sensitivity to FDA warnings.
Highlights
prospective audit and feedback (PAF) and prior approval implementation strategies focused on fluoroquinolones were associated with significantly lower fluoroquinolone prescribing rates and nonsignificant decreases in total antibiotic use, suggesting limited evidence for class substitution
The US Food and Drug Administration (FDA) has issued multiple safety communications on the fluoroquinolone class. These statements recommend use of alternative antibiotics for common infections because adverse events associated with the fluoroquinolone class outweigh potential benefits in some situations.[1]
In facilities with fluoroquinolone PAF and/or prior approval implementation strategies there was no change in advanced-generation cephalosporin days of therapy rate (P = .10) (Fig. 2a), but we detected a significant increase in cephalosporin rates in the facilities without fluoroquinolone PAF and/or prior approval (P = .001) (Fig. 2b)
Summary
Stewardship champions at 15 hospitals were surveyed regarding the use and acceptability of strategies to improve fluoroquinolone prescribing. A cross-sectional survey was conducted with antimicrobial stewardship champions at 15 acute-care facilities in April 2018. Study data were collected and managed using REDCap electronic data capture tools. The sample included VA medical centers enrolled in a Practice-Based Research Network (PBRN) jointly supported by the CDC and the VA. The sampling strategy included all VA PBRN facilities to ensure that we captured the diversity of perceptions and implemented practices. The antimicrobial stewardship leader was defined as the facility personnel designated to direct antimicrobial stewardship. The survey focused on the local implementation and acceptability of different strategies to improve fluoroquinolone prescribing
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