Development and Assessment of a Physician-Specific Antimicrobial Usage and Spectrum Feedback Tool

Physician antimicrobial prescribing and patient outcomes on general medical wards: a multicentre retrospective cohort study

BACKGROUND

Variability in antimicrobial prescribing may indicate an opportunity for improvement in antimicrobial use. We sought to measure physician-level antimicrobial prescribing in adult general medical wards, assess the contribution of patient-level factors to antimicrobial prescribing and evaluate the association between antimicrobial prescribing and clinical outcomes.

METHODS

Using the General Medicine Inpatient Initiative (GEMINI) database, we conducted a retrospective cohort study of physician-level volume and spectrum of antimicrobial prescribing in adult general medical wards in 4 academic teaching hospitals in Toronto, Ontario, between April 2010 and December 2019. We stratified physicians into quartiles by hospital site based on volume of antimicrobial prescribing (days of therapy per 100 patient-days and antimicrobial-free days) and antibacterial spectrum (modified spectrum score). The modified spectrum score assigns a value to each antibacterial agent based on the breadth of coverage. We assessed patient-level differences among physician quartiles using age, sex, Laboratory-based Acute Physiology Score, discharge diagnosis and Charlson Comorbidity Index. We evaluated the association of clinical outcomes (in-hospital 30-day mortality, length of stay, intensive care unit [ICU] transfer and hospital readmission) with antimicrobial volume and spectrum using multilevel modelling.

RESULTS

The cohort consisted of 124 physicians responsible for 124 158 hospital admissions. The median physician-level volume of antimicrobial prescribing was 56.1 (interquartile range 51.7-67.5) days of therapy per 100 patient-days. We did not find any differences in baseline patient characteristics by physician prescribing quartile. The difference in mean prescribing between quartile 4 and quartile 1 was 15.8 days of therapy per 100 patient-days (95% confidence interval [CI] 9.6-22.0), representing 30% higher antimicrobial prescribing in the fourth quartile than the first quartile. Patient in-hospital deaths, length of stay, ICU transfer and hospital readmission did not differ by physician quartile. In-hospital mortality was higher among patients cared for by prescribers with higher modified spectrum scores (odds ratio 1.13, 95% CI 1.04-1.24).

INTERPRETATION

We found that physician-level variability in antimicrobial prescribing was not associated with differences in patient characteristics or outcomes in academic general medicine wards. These findings provide support for considering the lowest quartile of physician antimicrobial prescribing within each hospital as a target for antimicrobial stewardship.

Antimicrobial stewardship failure: time for a new model

There are now 10 years of national antimicrobial consumption data in Ireland. Despite the creation of an 'antimicrobial stewardship and infection control industrial complex' over this period, the data demonstrate a 16% increase in consumption nationally. Given the ongoing challenges with carbapenemase-producing Enterobacterales and Clostridioides difficile within the acute hospital system, the data point to the ineffectiveness of the national antimicrobial stewardship programme/model. A different model of antimicrobial stewardship is therefore needed. This new model is one based around the collection and dissemination of physician-specific consumption, together with greater education of clinicians in the management of infections. By shining a light on individual clinician antibiotic prescribing, outlier identification, along with peer to peer (or clinician to clinician) pressure, can be brought to bear on the problem and shift the emphasis from the current 'policing' oversight, to self-regulation instead.

Evaluation of an initiative to improve prophylactic antimicrobial prescribing in patients on extracorporeal membrane oxygenation (ECMO) through the application of three antimicrobial-spectrum scores

Antimicrobial spectrum scoring is a method to quantify the spectrum of antimicrobial utilization. Herein, we applied a locally adapted scoring system, with other pre-existing scoring systems, using a data set of prophylactically administered antibiotics following a 2-stage antimicrobial stewardship program (ASP) intervention in a population of patients on extracorporeal membrane oxygenation (ECMO).

Small and Large Animal Veterinarian Perceptions of Antimicrobial Use Metrics for Hospital-Based Stewardship in the United States

Background: Robust measurement and tracking of antimicrobial use (AMU) is a fundamental component of stewardship interventions. Feeding back AMU metrics to individual clinicians is a common approach to changing prescribing behavior. Metrics must be meaningful and comprehensible to clinicians. Little is known about how veterinary clinicians working in the United States (US) hospital setting think about AMU metrics for antimicrobial stewardship. Objective: To identify hospital-based veterinary clinicians' attitudes toward audit and feedback of AMU metrics, their perceptions of different AMU metrics, and their response to receiving an individualized prescribing report. Methods: Semi-structured interviews were conducted with veterinarians working at two hospitals in the Eastern US. Interviews elicited perceptions of antimicrobial stewardship in veterinary medicine. Respondents were shown a personalized AMU Report characterizing their prescribing patterns relative to their peers and were asked to respond. Interviews were recorded, transcribed, and analyzed using the framework method with matrices. Results: Semi-structured interviews were conducted with 34 veterinary clinicians (22 small animal and 12 large animal). Respondents generally felt positive about the reports and were interested in seeing how their prescribing compared to that of their peers. Many respondents expressed doubt that the reports accurately captured the complexities of their prescribing decisions and found metrics associated with animal daily doses (ADDs) confusing. Only 13 (38.2%) respondents felt the reports would change how they used antimicrobials. When asked how the impact of the reports could be optimized, respondents recommended providing a more detailed explanation of how the AMU metrics were derived, education prior to report roll-out, guidance on how to interpret the metrics, and development of meaningful benchmarks for goal-setting. Conclusions: These findings provide important insight that can be used to design veterinary-specific AMU metrics as part of a stewardship intervention that are meaningful to clinicians and more likely to promote judicious prescribing.

Driving antimicrobial use improvement: attitudes of providers of adult hospital care on optimal attribution and feedback

Understanding provider perceptions of antimicrobial use (AU) feedback is important for optimal implementation. A survey addressing AU attribution scenarios, feedback methods, and implementation barriers was distributed to inpatient providers. As AU scenarios became more complex, disagreement regarding AU attribution arose. All providers were highly concerned about barriers to AU reporting.