Intervention to Improve Performance of Antimicrobial Automatic Stop Orders

Abstract

Background. Antimicrobial stewardship programs (ASP) have been shown to decrease inappropriate antibiotic use, improve patient outcomes, and decrease antimicrobial resistance. Automatic stop orders (ASO) of antimicrobial medications have been recommended as a component of ASPs and have been shown to reduce duration of therapy. However, some studies have revealed that ASOs can unintentionally discontinue or interrupt treatment. In our health system, which uses 7-day antimicrobial ASO, the ASP teams introduced a multifaceted intervention, which included increasing visibility of prophylactic antibiotic orders with a 90-day ASO and implementing a prospective review of all antimicrobials that expired by ASO using a novel electronic dashboard. Methods. This study was a retrospective, descriptive analysis of interventions made by the ASP teams over the 4-month period following implementation. As a proxy measure for missed medication doses, the rates of missed doses of trimethoprim- sulfamethoxazole (TMP-SMX) single strength (SS) daily before and after implementation were determined. Because TMP-SMX SS daily is almost exclusively used in prophylaxis, it would be unlikely to be interrupted intentionally. Results. A total of 855 medications were reviewed by the ASP teams in our health system from 1 November 2015 to 30 April 2016. This review resulted in 216 interventions in which a member of the patient's care team was contacted. The rate of missed Bactrim TMP-SMX doses decreased from 3.8% in the 2 months prior to the intervention to 1.6% in the 2 months after (p < 0.002). Conclusion. Although ASOs have been shown to reduce inappropriate antimicrobial use, they may also interrupt or prematurely shorten treatment courses. By increasing provider awareness of the ability to order longer courses of prophylactic antimicrobials and by streamlining the process of reviewing ASOs, ASPs can prevent potential medication errors resulting from ASOs.