Antimicrobial Stewardship: Analysis of Provider Management of Drug-Bug Mismatch in Multi-Drug Resistant Organisms in a Large Medical Group

Abstract

BACKGROUND The Centers for Disease Control and Prevention (CDC) estimates that 50% of antibiotics used in the outpatient setting are ordered inappropriately. Inappropriate antibiotics can lead to adverse patient outcomes, including clostridium difficile infection and antibiotic-resistant organisms. The purpose of this study is to review inappropriate antibiotic selection, drug-bug mismatch, in a large medical group. METHODS In a large multi-specialty medical group, encompassing 450 sites of care, multi-drug resistant organisms (MDROs) were identified by the microbiology department. Culture results included all MDROs identified from June 1 to August 31, 2018. The infection prevention department, upon receipt of the MDRO surveillance data, reviewed the electronic health record (EHR) for potential drug-bug mismatch. Providers were given 24 hours to address the drug-bug mismatch before infection prevention intervention. RESULTS A total of 179 MRDO cases were reviewed. 47 of the cases (26%) had a drug-bug mismatch. In 41 out of the 47 cases (87%), the provider recognized the drug-bug mismatch before the 24 hour timeframe and changed to effective antimicrobial therapy. 6 out of the 47 cases (13%) required infection prevention intervention. Of the 47 drug-bug mismatches identified, 30 (64%) were Methicillin-resistant Staphylococcus aureus (MRSA) in various wound cultures. 17 (36%) were Escherichia coli or Klebsiella pneumoniae Extended Spectrum Beta-Lactamases (ESBL) producing organisms. CONCLUSIONS This review identifies that providers in a large medical group most often manage drug-bug mismatches appropriately. This model of infection prevention intervention identifies 6 patients (13%) that benefited from early identification of inappropriate antimicrobial selection. The Centers for Disease Control and Prevention (CDC) estimates that 50% of antibiotics used in the outpatient setting are ordered inappropriately. Inappropriate antibiotics can lead to adverse patient outcomes, including clostridium difficile infection and antibiotic-resistant organisms. The purpose of this study is to review inappropriate antibiotic selection, drug-bug mismatch, in a large medical group. In a large multi-specialty medical group, encompassing 450 sites of care, multi-drug resistant organisms (MDROs) were identified by the microbiology department. Culture results included all MDROs identified from June 1 to August 31, 2018. The infection prevention department, upon receipt of the MDRO surveillance data, reviewed the electronic health record (EHR) for potential drug-bug mismatch. Providers were given 24 hours to address the drug-bug mismatch before infection prevention intervention. A total of 179 MRDO cases were reviewed. 47 of the cases (26%) had a drug-bug mismatch. In 41 out of the 47 cases (87%), the provider recognized the drug-bug mismatch before the 24 hour timeframe and changed to effective antimicrobial therapy. 6 out of the 47 cases (13%) required infection prevention intervention. Of the 47 drug-bug mismatches identified, 30 (64%) were Methicillin-resistant Staphylococcus aureus (MRSA) in various wound cultures. 17 (36%) were Escherichia coli or Klebsiella pneumoniae Extended Spectrum Beta-Lactamases (ESBL) producing organisms. This review identifies that providers in a large medical group most often manage drug-bug mismatches appropriately. This model of infection prevention intervention identifies 6 patients (13%) that benefited from early identification of inappropriate antimicrobial selection.