To the Editor—We read with interest the recent article in Clinical Infectious Diseases by Tamma et al [1], which focused on the efficacy of different antimicrobial stewardship methods, demonstrating that post-prescription review with feedback (PPRF) was more effective at reducing antimicrobial consumption over time than pre-prescription authorization. The study was performed on medical inpatients, but hospitals contain many other cohorts, such as surgical inpatients, in whom antimicrobial use is also high and often inappropriate [2]. PPRF can take many forms but is invariably both human resource and time intensive. Many hospitals may lack the resources to initiate this level of stewardship universally [3, 4], and there is therefore a need to identify the form of PPRF that most efficiently impacts inappropriate antimicrobial prescribing [5, 6].
We performed a prospective, observational study that compared different forms of PPRF: ward round reviews on acute medical wards, ward round reviews on surgical recovery wards, and telephone reviews with clinical teams caring for patients receiving carbapenems, cephalosporines, or quinolones. Each stewardship review episode was performed by 2 microbiologists and a pharmacist, who collected no more data than needed for routine practice and were not aware that the data would be used comparatively in the study. The 3 stewardship modalities occurred daily for 45, 90, or 60 minutes—for medical rounds, surgical rounds, and telephone reviews, respectively—and there was no overlap in the patients reviewed. All antimicrobial prescriptions reviewed were quantified and any intervention was recorded, with an intervention defined as a change to antimicrobial prescription, including starting or stopping treatment with a medication or modifying the duration of treatment or mode of administration. For the purpose of comparison, we considered telephone stewardship to be the control group. We calculated both the proportion of reviews resulting in an intervention and the rate of intervention per hour of stewardship across the 3 stewardship modalities.
A total of 1928 antimicrobial prescriptions were reviewed. Both surgical (37.24%) and medical (9.35%) stewardship ward rounds resulted in a significantly higher proportion of interventions than telephone reviews (4.34%) (Table 1). However, after controlling for time, the rate of interventions per hour was higher for medical stewardship rounds (2.26 interventions / hour) than for both surgical (1.70 interventions / hour) and telephone (0.48 interventions / hour) rounds (Table 1).
Table 1.
Number, Proportion and Rate of Interventions by Stewardship Modality
| Stewardship Approach | Prescriptions Reviewed, No. | Stewardship Interventions | Intervention Rate, Interventions per Hour of Stewardship (95% CI) | Hazard Ratio (95% CI) |
|
|---|---|---|---|---|---|
| No. (%) | Odds Ratio (95% CI) | ||||
| Telephone | 691 | 30 (4.34) | … | 0.48 (.34–.69) | … |
| Medical round | 802 | 75 (9.35) | 2.27 (1.46–3.52) | 2.26 (1.8–2.83) | 4.69 (3.07–7.17) |
| Surgical round | 435 | 162 (37.24) | 13.07 (8.64–19.79) | 1.70 (1.36–1.98) | 3.53 (2.39–5.21) |
Abbreviation: CI, confidence interval.
In conclusion, our study supports the observations made by Tamma et al [1] that hospital ward–based PPRF, though resource intensive, is an effective form of antimicrobial stewardship. We extend their findings by raising the importance of time efficiency, demonstrating that although surgical patient stewardship rounds result in a high absolute number and proportion of interventions, they are labor intensive, and medical ward rounds resulted in a similar number of interventions per hour of stewardship time. Both approaches were significantly better than telephone stewardship in terms of both the proportion and rate of stewardship interventions. We propose that other hospitals looking to assess and prioritize the impact of their stewardship programs should also incorporate a standardized time-based measure of stewardship efficiency.
Notes
Financial support. This work was supported by the Wellcome Trust (grant WT101766/Z/13/Z to G. P.).
Potential conflicts of interest. Author certifies no potential conflicts of interest. All author has submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.
References
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