Review and Comparison of Interventions Designed to Promote Appropriate Antimicrobial Coverage with those Designed to Reduce Antimicrobial Selective Pressure in a Comprehensive Antimicrobial Stewardship Program, 2007-2009

Background: Antimicrobial stewardship programs (ASP) can employ interventions designed to promote appropriate antimicrobial coverage and reduce antimicrobial selective pressure. At our hospital, we utilize an electronic program to alert ASP pharmacists of the need for potential interventions. The pharmacists then log their interventions, rationale and outcomes in a database.

Objective: To evaluate ASP interventions for adult medical and surgical services in an urban, academic medical center for a 3-year period. 

Methods: Interventions were classified into those designed to promote appropriate antimicrobial coverage and those designed to decrease antimicrobial selective pressure. The outcomes of these interventions were then stratified based on whether or not the treating clinician 1) accepted the recommendation of the pharmacist; 2) the ASP pharmacist agreed with original patient management; 3) different management than the original recommendation was agreed upon; 4) the original plan was continued despite ASP intervention; 5) original plan stopped but ASP pharmacist still disagreed with management.

Results: For the time period of 2007-2009, there were 447 interventions designed to promote appropriate antimicrobial coverage and 1,679 interventions designed to decrease antimicrobial selective pressure.

   

	Original management changed to different therapy from ASP recommendation but ASP agreed with final plan	ASP agreed with continuing original management	ASP original recommendation guided future therapy	Overall concurrence- ASP agreed with final management	Overall non-concurrence-ASP disagreed with final management
Interventions to promote appropriate antimicrobial coverage	34 (8%)	119 (26%)	228 (51%)	381 (85%)	66 (15%)
Interventions to reduce antimicrobial selective pressure	45 (3%)	363 (21%)	806 (48%)	1,214 (72%)	465 (28%)

Conclusions:

1. Interventions to reduce selective pressure were nearly 4-fold more common than interventions to provide adequate coverage.
2. For both types of interventions, half of the ASP pharmacists’ recommendations were accepted.
3. The ASP pharmacist agreed with the ultimate management 85% of the time for interventions designed to promote appropriate antimicrobial coverage, versus only 72% percent for interventions designed to decrease antimicrobial selective pressure. 
4. Antimicrobial stewardship programs that employ active interventions should track these in order to inform program efforts.