Antimicrobial Stewardship at a Long Term Acute Care Hospital (LTACH)

Background:   Long term acute care hospitals (LTACHs) are post-acute care facilities which provide care to medically complex patients in whom multi-drug resistant organisms are highly prevalent.  There are limited published data on antibiotic use and antimicrobial stewardship programs (ASPs) in this setting. 

Objective:   To assess the impact of the first 11 months of a formal ASP on antimicrobial use and costs at a free standing 60 bed LTACH in Dallas, TX.

Methods:   Acquisition costs and quantities of all oral and parenteral antibacterial, antifungal and antiviral agents were recorded monthly Jan 2009 through Oct 2010.  Antimicrobial use, measured as defined daily doses (WHO Collaborating Centre for Drug Statistics Methodology) per 1000 patient days (DDD per 1000 PD), and costs, measured as acquisition costs per patient day (CPPD), were calculated for each agent and formulation.  A formal ASP utilizing a strategy of concurrent audit with formal feedback was implemented Dec 2009 and continued through Oct 2010:  an ASP team (an infectious diseases (ID) specialist physician and a clinical pharmacist) met for one hour once weekly to review records of patients receiving antimicrobials.  Indications for antimicrobial therapy, duration, spectrum, route, clinical response, lab and culture data, allergies, and concurrent medications were reviewed.  Written non binding recommendations were made using a standard communication form to continue, discontinue, simplify, change route, alter schedule, revise dose or duration, or to formally consult ID, and were scored for implementation.  Neither formulary restriction nor preauthorization were employed.  The mean monthly use and cost data from the pre-ASP baseline period (Jan 2009 through Nov 2009) were compared to those of the ASP intervention period (Dec 2009 through Oct 2010) by unpaired two-tailed t-test with P < 0.05 as the level of significance.  95% Confidence Intervals were calculated for the differences between the means.

Results:   203 patient records were reviewed during the 11 month ASP period; recommendations were accepted for 153 (81%) of the 190 patients for whom recommendations were made.  There were 513 admissions during the pre-AST baseline period and 509 during the ASP period.  Mean antimicrobial use decreased 16% from a baseline of 981 to 821 DDD per 1000 PD (P = 0.017).   For antibacterial agents alone, mean use decreased 20% from 904 to 723 DDD per 1000 PD (P = 0.009).  Mean use of levofloxacin decreased 39% from 128 to 78 DDD per 1000 PD (P = 0.030).  Mean antimicrobial acquisition costs decreased 23% from $28.87 to $22.16 PPD (P = 0.018).  For antibacterial agents alone, mean acquisition costs decreased 29% from $26.72 to $19.01 PPD (P = 0.005).

Conclusions:   An ASP utilizing a once weekly review of patient records with formal recommendations was successfully implemented at a free standing urban LTACH and was associated with significant decreases in antimicrobial use and acquisition costs.