Center for Access & Delivery Research & Evaluation (CADRE), Iowa City Veterans Affairs Health Care System, Iowa City, IA, USA.
Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA.
J Antimicrob Chemother. 2021 Apr 13;76(5):1358-1365. doi: 10.1093/jac/dkab008.
Carbapenems are an important target for antimicrobial stewardship (AS) efforts. In this study, we sought to compare different hospital-based strategies for improving carbapenem use.
We analysed a cohort of all patients hospitalized at Veterans Health Administration (VHA) acute care hospitals during 2016 and a mandatory survey that characterized each hospital's carbapenem-specific AS strategy into one of three types: no strategy (NS), prospective audit and feedback (PAF) or restrictive policies (RP). Carbapenem use was compared using risk-adjusted generalized estimating equations that accounted for clustering within hospitals. Two infectious disease (ID) physicians independently performed manual chart reviews in 425 randomly selected cases. Auditors assessed carbapenem appropriateness with an assessment score on Day 4 of therapy.
There were 429 062 admissions in 90 sites (24 NS, 8 PAF, 58 RP). Carbapenem use was lower at PAF than NS sites [rate ratio (RR) 0.6 (95% CI 0.4-0.9); P = 0.01] but similar between RP and NS sites. Carbapenem prescribing was considered appropriate/acceptable in 215 (50.6%) of the reviewed cases. Assessment scores were lower (i.e. better) at RP than NS sites (mean 2.3 versus 2.7; P < 0.01) but did not differ significantly between NS and PAF sites. ID consultations were more common at PAF/RP than NS sites (51% versus 29%; P < 0.01). ID consultations were associated with lower (i.e. better) assessment scores (mean 2.3 versus 2.6; P < 0.01).
In this VHA cohort, PAF strategies were associated with lower carbapenem use and ID consultation and RP strategies were associated with more appropriate carbapenem prescribing. AS and ID consultations may work complementarily and hospitals could leverage both to optimize carbapenem use.
碳青霉烯类抗生素是抗菌药物管理（AS）的重要目标。本研究旨在比较不同的基于医院的策略，以改善碳青霉烯类抗生素的使用。
我们分析了 2016 年退伍军人健康管理局（VHA）急性护理医院所有住院患者的队列，并对每个医院的碳青霉烯类抗生素特定 AS 策略进行了强制性调查，将其分为三种类型：无策略（NS）、前瞻性审核和反馈（PAF）或限制性政策（RP）。使用风险调整的广义估计方程比较碳青霉烯类抗生素的使用情况，该方程考虑了医院内的聚类。两名传染病（ID）医生在 425 例随机选择的病例中独立进行了手动图表审查。审核员在治疗的第 4 天使用评估评分评估碳青霉烯类抗生素的适当性。
90 个地点有 429062 例住院患者（24 个 NS、8 个 PAF、58 个 RP）。PAF 比 NS 地点的碳青霉烯类抗生素使用率低[比值比（RR）0.6（95%CI 0.4-0.9）；P=0.01]，但 RP 与 NS 地点之间没有差异。在审查的病例中，215 例（50.6%）碳青霉烯类抗生素的处方被认为是适当/可接受的。评估评分在 RP 比 NS 地点低（即更好）（平均 2.3 比 2.7；P<0.01），但 NS 与 PAF 地点之间没有显著差异。PAF/RP 比 NS 地点更常见 ID 咨询（51%比 29%；P<0.01）。ID 咨询与较低（即更好）的评估评分相关（平均 2.3 比 2.6；P<0.01）。
在这个 VHA 队列中，PAF 策略与较低的碳青霉烯类抗生素使用和 ID 咨询相关，而 RP 策略与更适当的碳青霉烯类抗生素处方相关。AS 和 ID 咨询可能互补，医院可以利用两者来优化碳青霉烯类抗生素的使用。
