A Hospitalist-Led Initiative to Promote Antibiotic Citizenship on Internal Medicine Teaching Services

Abstract

Background. Hospitalists are critical partners in antimicrobial stewardship program (ASP) efforts to improve antimicrobial use, but limited data exists on the effectiveness of ASP-hospitalist collaboration. We performed a hospitalist-led quality improvement project with pharmacy collaboration to improve antimicrobial prescribing practices on general internal medicine teaching services at an urban academic medical center. Methods. We conducted a 3-arm intervention study on internal medicine teaching services from September-December 2016. Three services received an educational (Ed) intervention consisting of an antibiotic rationale checklist, a templated progress note to promote trainee critical thinking about antibiotic management, and a pocket card with institutional guidelines. In addition, 1 team received twice weekly stewardship rounds with an infectious disease clinical pharmacist (Ed+ID-PharmDx2) while another team received 5x week stewardship rounds with a generalist clinical pharmacist (Ed+PharmDx5). The primary outcome was broad-spectrum antibiotic use calculated as days of therapy (DOT) per 1000 patient days compared with historical data from the corresponding months. Secondary outcomes included duration of inpatient therapy, antibiotic costs, length of stay, 30-day readmission, ICU transfer and in-hospital mortality. Results. Broad-spectrum antibiotic use significantly decreased by 26% (415 vs. 306 DOT/1000 patient days) and 32% (425 vs. 287 DOT per 1000 patient days) on the Ed and Ed+PharmDx5 teams, respectively (P <0.01). Broad-spectrum use on the ED+ID-PharmDx2 team decreased by 9% but was not statistically significant. There was a significant improvement in median length of stay among patients receiving antibiotics for Ed only (-1.5 days; P < 0.001) and Ed+PharmDx5 (-1 day; P < 0.001) and no significant change in 30 day readmissions, ICU transfer and in-hospital mortality for any team. Direct antibiotic costs were reduced by $80,000 during the study period. Conclusion. A hospitalist-led initiative to improve inpatient antimicrobial prescribing led to reductions in broad-spectrum antimicrobial use and reduced length of stay. ASPs should target hospitalists and pharmacists as partners in programmatic efforts to improve inpatient antimicrobial prescribing.