Exploring unconventional antimicrobial stewardship models: options beyond traditional prospective audit and feedback

Prospective audit and feedback (PAF) is a core antimicrobial stewardship strategy. Discontinuing PAF in favor of alternative interventions has not been previously evaluated.

This descriptive study assessed changes in antimicrobial days of therapy per 1,000 patient days (DOTs/1,000 PD) following PAF removal at two urban hospitals. Preintervention PAF included daily review of broad-spectrum antibiotics and oral therapy transitions. Postintervention efforts emphasized system standardization, education, guideline optimization, and electronic medical record enhancements. Secondary outcomes included trends in antibiotics previously reviewed under PAF: antibiotics targeting methicillin-resistant Staphylococcus aureus (MRSA) or Pseudomonas aeruginosa, carbapenems, and oral antibiotics.

Hospital A demonstrated a change in the trend of DOTs/1,000 PD with a significant downward slope after PAF removal (-5.994; 95% CI -8.072 to -3.929; P < .001). Hospital B continued to down-trend postintervention. At hospital A, carbapenem use decreased significantly postintervention (slope change -0.117; 95% CI -0.198 to -0.036; P = .007), with no changes in anti-MRSA or anti-pseudomonal agents. Hospital B demonstrated increasing use of anti-MRSA (slope change + 0.394; 95% CI 0.198 to 0.589; P < .001), anti-pseudomonal (slope change + 0.378; 95% CI 0.075 to 0.681; P = .016), and carbapenem agents (slope change + 0.124; 95% CI 0.020 to 0.228; P = .021). No changes were observed in oral antibiotic use or C. difficile rates.

Shifting stewardship resources away from PAF did not increase total antibiotic use trends. Broad-spectrum antibiotics increased modestly with unclear clinical significance (≤1.3 DOT/1,000 PD). Antimicrobial stewardship strategies, beyond PAF, should continue to be assessed to maximize effectiveness relative to effort.