Computerized Physician Order-Entry Antimicrobial Stewardship Program Targeting Linezolid, in the Presence of an Infectious Disease Physician, Can Significantly Impact its Use in the Community Hospital Setting

Background: The implementation of antimicrobial stewardship programs (ASPs) in the community setting, utilize strategies in the presence of an infectious disease (ID) physician such as prospective audits with intervention and feedback, formulary restriction, and pre-authorization. However, little is known regarding the impact of a proactive, computerized physician order entry (CPOE) system in the presence of an existing ASP. 

Objective: To prospectively determine the impact of a proactive, CPOE-ASP in two community hospitals, one with and the other without the presence of an ID physician.

Methods: A CPOE-ASP addressing the utilization of linezolid was implemented in two community hospitals serving two suburban centers of Maricopa County, AZ over a 16 month period before and after its implementation.  The 214-bed facility (Hospital A) incorporated an ID physician to direct the ASP while the 165-bed facility (Hospital B) ASP operated in the absence of an ID physician. Linezolid prescribers are presented with a dialog window summarizing the current approved usages, as well as alternative antibiotics and hyperlinks to evidence-based articles. Utilization was prospectively monitored using monthly hospital pharmacy purchasing data  to obtain the defined daily dose (DDD) per 1000 patient-days. A medication utilization evaluation (MUE) was performed to assess the appropriateness of linezolid ordering. Mann-Whitney U and the Fisher Exact tests were used for statistical analysis when appropriate.

Results: Linezolid use in Hospital A decreased significantly from 44 to 28 DDD per 1000 patient-days (p<0.03) in the presence of an ID physician leading an existing program (Figure 1).  The subsequent introduction of a CPOE-ASP significantly decreased linezolid usage to 7.5 DDD/1000 patient days (Figure 1, p<0.001).  In contrast, linezolid use in Hospital B was lower from the onset when compared to Hospital A, and did not improve with the initiation of CPOE-ASP (from 0.78 to 1.03 DDD/1000 patient days).  After initiating CPOE-ASP, Hospital A's total expenditures for linezolid decreased, resulting in cost savings well over $600,000 over the past 16 months.  The MUE of Hospital A showed that the percentage of inappropriate linezolid orders dropped significantly from 77% to 11% (p<0.0001), with a modest decrease in inappropriate linezolid orders described with Hospital B (60% to 36%).

Conclusions: These results suggest that a proactive, computerized physician order entry (CPOE) system can be successfully initiated in the presence of an ID physician leading an ASP in the community hospital setting, impacting both the prescribing habits of hospital practitioners and can significantly decrease hospital expenditures of this medication. 

Stewardship Program