Hostname: page-component-586b7cd67f-vdxz6 Total loading time: 0 Render date: 2024-11-25T23:08:32.507Z Has data issue: false hasContentIssue false

Top 1% of Inpatients Administered Antimicrobial Agents Comprising 50% of Expenditures: A Descriptive Study and Opportunities for Stewardship Intervention

Published online by Cambridge University Press:  05 December 2016

Jennifer Dela-Pena
Affiliation:
Department of Pharmacy, UW Health, Madison, Wisconsin
Luiza Kerstenetzky
Affiliation:
Department of Pharmacy, UW Health, Madison, Wisconsin
Lucas Schulz*
Affiliation:
Department of Pharmacy, UW Health, Madison, Wisconsin
Ron Kendall
Affiliation:
Department of Pharmacy, UW Health, Madison, Wisconsin
Alexander Lepak
Affiliation:
Division of Infectious Diseases, Department of Medicine, UW Health, Madison, Wisconsin
Barry Fox
Affiliation:
Division of Infectious Diseases, Department of Medicine, UW Health, Madison, Wisconsin
*
Address correspondence to Lucas Schulz, PharmD, Department of Pharmacy, UW Health, 600 Highland Ave, Madison, WI 53792 ([email protected]).

Abstract

OBJECTIVE

To characterize the top 1% of inpatients who contributed to the 6-month antimicrobial budget in a tertiary, academic medical center and identify cost-effective intervention opportunities targeting high-cost antimicrobial utilization.

DESIGN

Retrospective cohort study.

PATIENTS

Top 1% of the antimicrobial budget from July 1 through December 31, 2014.

METHODS

Patients were identified through a pharmacy billing database. Baseline characteristics were collected through a retrospective medical chart review. Patients were presented to the antimicrobial stewardship team to determine appropriate utilization of high-cost antimicrobials and potential intervention opportunities. Appropriate use was defined as antimicrobial therapy that was effective, safe, and most cost-effective compared with alternative agents.

RESULTS

A total of 10,460 patients received antimicrobials in 6 months; 106 patients accounted for $889,543 (47.2%) of the antimicrobial budget with an antimicrobial cost per day of $219±$192 and antimicrobial cost per admission of $4,733±$7,614. Most patients were immunocompromised (75%) and were followed by the infectious disease consult service (80%). The most commonly prescribed antimicrobials for treatment were daptomycin, micafungin, liposomal amphotericin B, and meropenem. Posaconazole and valganciclovir accounted for most of the prophylactic therapy. Cost-effective opportunities (n=71) were present in 57 (54%) of 106 patients, which included dose optimization, de-escalation, dosage form conversion, and improvement in transitions of care.

CONCLUSION

Antimicrobial stewardship oversight is important in implementing cost-effective strategies, especially in complex and immunocompromised patients who require the use of high-cost antimicrobials.

Infect Control Hosp Epidemiol 2017;38:259–265

Type
Original Articles
Copyright
© 2016 by The Society for Healthcare Epidemiology of America. All rights reserved 

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

REFERENCES

1. Huttner, A, Harbarth, S, Carlet, J, et al. Antimicrobial resistance: a global view from the 2013 World Healthcare-Associated Infections Forum. Antimicrob Resist Infect Control 2013;2:31.CrossRefGoogle ScholarPubMed
2. de Kraker, ME, Wolkewitz, M, Davey, PG, et al. Burden of antimicrobial resistance in European hospitals: excess mortality and length of hospital stay associated with bloodstream infections due to Escherichia coli resistant to third-generation cephalosporins. J Antimicrob Chemother 2011;66:398407.CrossRefGoogle ScholarPubMed
3. de Kraker, ME, Wolkewitz, M, Davey, PG, et al. Clinical impact of antimicrobial resistance in European hospitals: excess mortality and length of hospital stay related to methicillin-resistant Staphylococcus aureus bloodstream infections. Antimicrob Agents Chemother 2011;55:15981605.CrossRefGoogle ScholarPubMed
4. Laxminarayan, R, Duse, A, Wattal, C, et al. Antibiotic resistance—the need for global solutions. Lancet Infect Dis 2013;13:10571098.CrossRefGoogle ScholarPubMed
5. Dellit, TH, Owens, RC, McGowan, JE Jr, et al. Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clin Infect Dis 2007;44:159177.CrossRefGoogle Scholar
6. Pollack, LA, Srinivasan, A. Core elements of hospital antibiotic stewardship programs from the Centers for Disease Control and Prevention. Clin Infect Dis 2014;59:S97100.CrossRefGoogle ScholarPubMed
7. Davey, P, Brown, E, Charani, E, et al. Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database Syst Rev 2013;4:CD003543.Google Scholar
8. Nguyen, CT, Gandhi, T, Chenoweth, C, et al. Impact of an antimicrobial stewardship-led intervention for Staphylococcus aureus bacteraemia: a quasi-experimental study. J Antimicrob Chemother 2015;70:33903396.Google ScholarPubMed
9. McNulty, C, Logan, M, Donald, IP, et al. Successful control of Clostridium difficile infection in an elderly care unit through use of a restrictive antibiotic policy. J Antimicrob Chemother 1997;40:707711.CrossRefGoogle Scholar
10. Lockwood, AM, Perez, KK, Musick, WL, et al. Integrating rapid diagnostics and antimicrobial stewardship in two community hospitals improved process measures and antibiotic adjustment time. Infect Control Hosp Epidemiol 2016;37:425432.CrossRefGoogle ScholarPubMed
11. Roberts, RR, Hota, B, Ahmad, I, et al. Hospital and societal costs of antimicrobial-resistant infections in a Chicago teaching hospital: implications for antibiotic stewardship. Clin Infect Dis 2009;49:11751184.CrossRefGoogle Scholar
12. Dik, JW, Vemer, P, Friedrich, AW, et al. Financial evaluations of antibiotic stewardship programs—a systematic review. Front Microbiol 2015;6:317.CrossRefGoogle ScholarPubMed
13. Borde, JP, Nussbaum, S, Hauser, S, et al. Implementing an intensified antibiotic stewardship programme targeting daptomycin use in orthopaedic surgery: a cost-benefit analysis from the hospital perspective [published online October 16, 2015]. Infection 2016;44:301307.CrossRefGoogle ScholarPubMed
14. Day, SR, Smith, D, Harris, K, Cox, HL, Mathers, AJ. An infectious diseases physician-led antimicrobial stewardship program at a small community hospital associated with improved susceptibility patterns and cost-savings after the first year. Open Forum Infect Dis 2015;2:ofv064.CrossRefGoogle Scholar
15. Standiford, HC, Chan, S, Tripoli, M, Weekes, E, Forrest, GN. Antimicrobial stewardship at a large tertiary care academic medical center: cost analysis before, during, and after a 7-year program. Infect Control Hosp Epidemiol 2012;33:338345.CrossRefGoogle Scholar
16. Schulz, L, Osterby, K, Fox, B. The use of best practice alerts with the development of an antimicrobial stewardship navigator to promote antibiotic de-escalation in the electronic medical record. Infect Control Hosp Epidemiol 2013;34:12591265.CrossRefGoogle ScholarPubMed
17. Schumock, GT, Li, EC, Suda, KJ, et al. National trends in prescription drug expenditures and projections for 2014. Am J Health Syst Pharm 2014;71:482499.CrossRefGoogle ScholarPubMed
18. Ng, JK, Schulz, LT, Rose, WE, et al. Daptomycin dosing based on ideal body weight versus actual body weight: comparison of clinical outcomes. Antimicrob Agents Chemother 2014;58:8893.CrossRefGoogle ScholarPubMed
19. Prybylski, JP. Vancomycin trough concentration as a predictor of clinical outcomes in patients with Staphylococcus aureus bacteremia: a meta-analysis of observational studies. Pharmacotherapy 2015;35:889898.CrossRefGoogle ScholarPubMed
20. Men, P, Li, HB, Zhai, SD, Zhao, RS. Association between the AUC0-24/MIC ratio of vancomycin and its clinical effectiveness: a systematic review and meta-analysis. PLOS ONE 2016;11:e0146224.CrossRefGoogle ScholarPubMed
21. Flume, PA, Mogayzel, PJ Jr., Robinson, KA, et al. Cystic fibrosis pulmonary guidelines: treatment of pulmonary exacerbations. Am J Respir Crit Care Med 2009;180:802808.CrossRefGoogle ScholarPubMed
22. Yeo, CL, Wu, JE, Chung, GW, Chan, DS, Chen, HH, Hsu, LY. Antimicrobial stewardship auditing of patients reviewed by infectious diseases physicians in a tertiary university hospital. Antimicrob Resist Infect Control 2013;2:29.CrossRefGoogle ScholarPubMed
23. Goldstein, EJ, Goff, DA, Reeve, W, et al. Approaches to modifying the behavior of clinicians who are noncompliant with antimicrobial stewardship program guidelines. Clin Infect Dis 2016;63:532538.CrossRefGoogle ScholarPubMed