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100 A Multifaceted Intervention to Decrease Inappropriate Piperacillin and Tazobactam Use and Its Effects on Cefepime Utilization and Hospital-Acquired Clostridium Difficile Associated Diarrhea Rates

Friday, March 19, 2010
Grand Hall (Hyatt Regency Atlanta)
Dmitry Kiyatkin, M.D. , Johns Hopkins Bayview Medical Center, Johns Hopkins School of Medicine, Baltimore, MD
Gina L. Bazemore, Pharm.D. , Johns Hopkins Bayview Medical Center, Johns Hopkins School of Medicine, Baltimore, MD
Jonathan M. Zenilman, M.D. , Johns Hopkins Bayview Medical Center, Johns Hopkins School of Medicine, Baltimore, MD
Catherine L. Passaretti, M.D. , Johns Hopkins Bayview Medical Center, Johns Hopkins School of Medicine, Baltimore, MD
Background: Inappropriate use of broad spectrum antibiotics is associated with increased antimicrobial resistance, high rates of Clostridium difficile associated diarrhea (CDAD) and increased costs.  In our institution, Piperacillin/Tazobactam (Pip/Tazo) is the most frequently used anti-pseudomonal drug and accounts for 13% of antibiotic costs.   Our rate of hospital acquired CDAD over the past 9 years has (HA-CDAD) been 1.09 cases/1000 patient days (pds) and has not decreased despite multiple prior interventions.

Objective: To evaluate Pip/Tazo usage and HA-CDAD after an implementation of a multifaceted intervention to decrease inappropriate Pip/Tazo utilization.

Methods: Pre-intervention, Pip/Tazo use was unrestricted. At baseline, a random prescription audit of Pip/Tazo orders was performed.  Baseline anti-pseudomonal agent usage (daily doses dispensed/1000 pds) was determined for the one year pre-intervention period.  A multifaceted intervention was then implemented, which included random weekday Pip/Tazo order review, academic detailing, and implementing an indication and rationale statement for the antibiotic at the time of initial order entry.  We compared antibiotic utilization and HA-CDAD rates during the 12 months before and after the intervention.

Results: The pre-intervention prescription reviews of Pip/Tazo determined that a narrower spectrum antibiotic was appropriate in 35% (95 out of 269 cases).  Pre-intervention, Pip/Tazo usage was 282 daily doses/1000 pds and cefepime usage was 24 daily doses/1000 pds.  Post-intervention Pip/Tazo usage decreased 21% to 224 daily doses/1000 pds, but cefepime utilization increased 75% to 42 daily doses/1000 pds Nevertheless, direct drug cost savings $57,000, and use of other anti-pseudomonal drugs was unchanged.  During the intervention year, HA-CDAD rate also decreased by 45% from 1.37 cases/1000 patient days to 0.76.

Conclusions: A relatively low cost set of interventions significantly decreased Pip/Tazo utilization leading to significant pharmacy cost savings and was associated with a substantial decrease in HA-CDAD rates and an unintended significant rise in cefepime utilization.