Audit and feedback of antibiotic use

Summary

Background: There is now little doubt that improving antimicrobial use is necessary for the containment of resistance.

Objective: To determine whether providing individualised feedback to doctors about their recent compliance with the hospital’s antibiotic policy improves compliance with the policy.

Methods: This study was conducted at a teaching hospital in Sydney, Australia. Computerised alerts integrated into the electronic prescribing system (ePS) inform prescribers of the local antibiotic policy. We utilised prescribing data extracted from the ePS for ‘audit and feedback’. Thirty-six prescribers were sent feedback letters via email. We also interviewed doctors who had received letters to explore their views of the feedback and the policy in general.

Results: There was no significant change in compliance with the policy following implementation of the feedback intervention (0% compliant vs 11.9%; p = 0.07). Several problems with the policy and the approval process were identified by researchers during auditing and by prescribers during interviews. Some problems identified made it difficult to accurately assess compliance and for doctors to comply with the policy.

Conclusions: Our intervention did not result in improved compliance with the antibiotic policy but revealed practical problems with the policy and approval process that had not been identified prior to the trial. Greater support for the policy by senior doctors and the assignment of more clearly defined roles and responsibilities associated with antibiotic use and approval may result in improved compliance. Harnessing the full potential of technology would streamline the antimicrobial approval process and allow more efficient and reliable monitoring of antibiotic use and compliance. Many of the problems we identified are generic issues of importance to all organisations seeking to integrate antimicrobial stewardship into ePS.

Citation: Baysari MT, Oliver K, Egan B, Li L, Richardson K, Sandaradura I, Westbrook J I, Day RO. Audit and feedback of antibiotic use: Utilising electronic prescription data. Appl Clin Inf 2013; 4: 583–595

http://dx.doi.org/10.4338/ACI-2013-08-RA-0063

Keywords

Antibiotic - compliance - audit and feedback - electronic prescribing

• References

• 1 Goossens H, Ferech M, Vander Stichele R, Elseviers M. Outpatient antibiotic use in Europe and association with resistance: a cross-national database study. The Lancet. 2005; 365 9459 579-87.
• 2 Okeke IN, Laxminarayan R, Bhutta ZA, Duse AG, Jenkins P, O’Brien TF, Pablos-Mendez A, Klugman KP. Antimicrobial resistance in developing countries. Part I: recent trends and current status. The Lancet Infectious Diseases 2005; 5 (Suppl. 08) 481-93.
• 3 WHO.. WHO Global strategy for containment of antimicrobial resistance. World Health Organization, 2001.
• 4 Gross PA, Pujat D. Implementing Practice Guidelines for Appropriate Antimicrobial Usage: A Systematic Review. Medical Care. 2001; 39 (Suppl. 08) II55-II69.
• 5 Charani E, Edwards R, Sevdalis N, Alexandrou B, Sibley E, Mullett D, Franklin BD, Holmes A. Behavior change strategies to influence antimicrobial prescribing in acute care: a systematic review. Clin Infect Dis. 2011; Oct 53 (Suppl. 07) 651-62.
• 6 Davey P, Sneddon J, Nathwani D. Overview of strategies for overcoming the challenge of antimicrobial resistance. Expert Rev Clin Pharmacol. 2010; Sep 3 (Suppl. 05) 667-86.
• 7 Paskovaty A, Pflomm JM, Myke N, Seo SK. A multidisciplinary approach to antimicrobial stewardship: evolution into the 21st century. International Journal of Antimicrobial Agents 2005; 25 (Suppl. 01) 1-10.
• 8 Steinman MA, Ranji SR, Shojania KG, Gonzales R. Improving antibiotic selection: a systematic review and quantitative analysis of quality improvement strategies. Med Care. 2006; Jul 44 (Suppl. 07) 617-28.
• 9 Duguid M, Cruickshank M. Antimicrobial Stewardship in Australian Hospitals. Sydney: Australian Commission on Safety and Quality in Healthcare,; 2011
• 10 Evans RS, Pestotnik SL, Classen DC, Clemmer TP, Weaver LK, Omre JF, Lloyd JF, Burke JP. A computer-assisted management program for antibiotics and other antiinfective agents. The New England Journal of Medicine 1998; 338 (Suppl. 04) 232-8.
• 11 McGregor JC, Weekes E, Forrest GN, Standiford HC, Perencevich EN, Furuno JP, Harris AD. Impact of a Computerized Clinical Decision Support System on Reducing Inappropriate Antimicrobial Use. Journal of the American Medical Informatics Association. 2006 July 1, 2006; 13 (Suppl. 04) 378-84.
• 12 Burke JP, Pestotnik SL. Antibiotic use and microbial resistance in intensive care units: impact of computer-assisted decision support. J Chemother 1999; Dec 11 (Suppl. 06) 530-5.
• 13 Shojania KG, Yokoe D, Platt R, Fiskio J, Ma’luf N, Bates DW. Reducing Vancomycin Use Utilizing a Computer Guideline: Results of a Randomized Controlled Trial. Journal of the American Medical Informatics Association. 1998 November 1, 1998; 5 (Suppl. 06) 554-62.
• 14 Buising KL, Thursky KA, Robertson MB, Black JF, Street AC, Richards MJ, Brown GV. Electronic antibiotic stewardship--reduced consumption of broad-spectrum antibiotics using a computerized antimicrobial approval system in a hospital setting. Journal of Antimicrobial Chemotherapy (JAC) [Article]. 2008; 62: 3-608
• 15 Richards MJ, Robertson MB, Dartnell JG, Duarte MM, Jones NR, Kerr DA, Lim LL, Ritchie PD, Stanton GJ, Taylor SE. Impact of a web-based antimicrobial approval system on broad-spectrum cephalosporin use at a teaching hospital. The Medical Journal of Australia. 2003 Apr 21 178. 08 386-90.
• 16 Cairns KA, Jenney AW, Abbott IJ, Skinner MJ, Doyle JS, Dooley M, Cheng AC. Prescribing trends before and after implementation of an antimicrobial stewardship program. The Medical Journal of Australia. [Comparative Study]. 2013 Mar 18 198 (Suppl. 05) 262-6.
• 17 Thursky KA, Buising KL, Bak N, Macgregor L, Street AC, Macintyre CR, Presneill JJ, Cade JF, Brown GV. Reduction of broad-spectrum antibiotic use with computerized decision support in an intensive care unit. International Journal for Quality in Health Care. 2006 June 1, 2006; 18 (Suppl. 03) 224-31.
• 18 Teo CK, Baysari MT, Day RO. Understanding compliance to antibiotic prescribing guidelines. Journal of Pharmacy Practice and Research 2013; 43: 32-6
• 19 Di Pentima MC, Chan S. Impact of antimicrobial stewardship program on vancomycin use in a pediatric teaching hospital. Pediatr Infect Dis J 2010; Aug 29 (Suppl. 08) 707-11.
• 20 McIntosh KA, Maxwell DJ, Pulver LK, Horn F, Robertson MB, Kaye KI, Peterson GM, Dollman WB, Wai A, Tett SE. A quality improvement initiative to improve adherence to national guidelines for empiric management of community-acquired pneumonia in emergency departments. International Journal for Quality in Health Care. 2011 April 1, 2011; 23 (Suppl. 02) 142-50.
• 21 Wright A, Sittig DF, Ash JS, Bates DW, Feblowitz J, Fraser G, Maviglia SM, McMullen C, Nichol WP, Pang JE, Starmer J, Middleton B. Governance for clinical decision support: case studies and recommended practices from leading institutions. Journal of the American Medical Informatics Association. 2011 March 1, 2011; 18 (Suppl. 02) 187-94.
• 22 Hulscher MEJL, Grol RPTM, van der Meer JWM. Antibiotic prescribing in hospitals: a social and behavioural scientific approach. The Lancet Infectious Diseases 2010; 10 (Suppl. 03) 167-75.
• 23 Cortoos P-J, Witte KD, Peetermans WE, Simoens S, Laekeman G. Opposing expectations and suboptimal use of a local antibiotic hospital guideline: a qualitative study. Journal of Antimicrobial Chemotherapy (JAC). [Article]. 2008 62. 1-189
• 24 Page MA, Bajorek BV, Brien JE. Prescribing in teaching hospitals: A qualitative study of social and cultural dynamics. Journal of Pharmacy Practice and Research 2008; 38 (Suppl. 04) 286-91.