Assessment of the Appropriateness of Antimicrobial Use in US Hospitals

Shelley S Magill,Christopher Evans,Sarah J Janelle,Rebecca Pierce,Alexia Y Zhang,Erin O’Leary,Shamima Sharmin,Susan M Ray,Helen Johnston,Valerie Ocampo,Meghan Maloney,Ghinwa Dumyati,Nora Chea,Tolulope Oyewumi,Jean Rainbow,Ruth Lynfield,Joelle Nadle,Linn Warnke,Lucy Wilson ,Samantha Greissman,Wendy Bamberg ,Deborah Thompson ,Marion Kainer ,Jonathan R Edwards,Melinda M Neuhauser

doi:10.1001/jamanetworkopen.2021.2007

Abstract

Hospital antimicrobial consumption data are widely available; however, large-scale assessments of the quality of antimicrobial use in US hospitals are limited. To evaluate the appropriateness of antimicrobial use for hospitalized patients treated for community-acquired pneumonia (CAP) or urinary tract infection (UTI) present at admission or for patients who had received fluoroquinolone or intravenous vancomycin treatment. This cross-sectional study included data from a prevalence survey of hospitalized patients in 10 Emerging Infections Program sites. Random samples of inpatients on hospital survey dates from May 1 to September 30, 2015, were identified. Medical record data were collected for eligible patients with 1 or more of 4 treatment events (CAP, UTI, fluoroquinolone treatment, or vancomycin treatment), which were selected on the basis of common infection types reported and antimicrobials given to patients in the prevalence survey. Data were analyzed from August 1, 2017, to May 31, 2020. Antimicrobial treatment for CAP or UTI or with fluoroquinolones or vancomycin. The percentage of antimicrobial use that was supported by medical record data (including infection signs and symptoms, microbiology test results, and antimicrobial treatment duration) or for which some aspect of use was unsupported. Unsupported antimicrobial use was defined as (1) use of antimicrobials to which the pathogen was not susceptible, use in the absence of documented infection signs or symptoms, or use without supporting microbiologic data; (2) use of antimicrobials that deviated from recommended guidelines; or (3) use that exceeded the recommended duration. Of 12 299 patients, 1566 patients (12.7%) in 192 hospitals were included; the median age was 67 years (interquartile range, 53-79 years), and 864 (55.2%) were female. A total of 219 patients (14.0%) were included in the CAP analysis, 452 (28.9%) in the UTI analysis, 550 (35.1%) in the fluoroquinolone analysis, and 403 (25.7%) in the vancomycin analysis; 58 patients (3.7%) were included in both fluoroquinolone and vancomycin analyses. Overall, treatment was unsupported for 876 of 1566 patients (55.9%; 95% CI, 53.5%-58.4%): 110 of 403 (27.3%) who received vancomycin, 256 of 550 (46.6%) who received fluoroquinolones, 347 of 452 (76.8%) with a diagnosis of UTI, and 174 of 219 (79.5%) with a diagnosis of CAP. Among patients with unsupported treatment, common reasons included excessive duration (103 of 174 patients with CAP [59.2%]) and lack of documented infection signs or symptoms (174 of 347 patients with UTI [50.1%]). The findings suggest that standardized assessments of hospital antimicrobial prescribing quality can be used to estimate the appropriateness of antimicrobial use in large groups of hospitals. These assessments, performed over time, may inform evaluations of the effects of antimicrobial stewardship initiatives nationally.

Highlights

Optimizing antimicrobial use is critical to slowing the spread of resistant pathogens
Treatment was unsupported for 876 of 1566 patients (55.9%; 95% CI, 53.5%-58.4%): 110 of 403 (27.3%) who received vancomycin, 256 of 550 (46.5%) who received fluoroquinolones, 347 of 452 (76.8%) with a diagnosis of urinary tract infection (UTI), and 174 of 219 (79.5%) with a diagnosis of community-acquired pneumonia (CAP)
Meaning The findings suggest that standardized assessments of hospital antimicrobial prescribing quality can be used to estimate the appropriateness of antimicrobial use in large groups of hospitals

Summary

Introduction

Optimizing antimicrobial use is critical to slowing the spread of resistant pathogens. In 2014, the US Centers for Disease Control and Prevention (CDC) called for acute care hospitals to implement antimicrobial stewardship programs with the goal of improving antimicrobial use to optimize infection cure rates and minimize harms.[1] In 2014 and 2015, the White House released the US National Strategy and Action Plan for Combating Antibiotic-Resistant Bacteria, which established antibiotic stewardship outcomes to accomplish by 2020, including a 20% reduction in inappropriate inpatient antibiotic use for monitored conditions and medications.[2,3] National initiatives have bolstered stewardship efforts in recent years, and data from the CDC’s National Healthcare Safety Network have shown increases in the percentage of hospitals with comprehensive antimicrobial stewardship programs.[1]. Hospital antimicrobial stewards often perform intensive, small-scale medication use evaluations to answer specific questions about appropriateness.

Methods

Results

Discussion

Conclusion