Clinical impact of a pharmacist-led antimicrobial stewardship initiative evaluating patients with Clostridioides difficile colitis

Clostridioides difficile is the most common cause of healthcare-associated infection and gastroenteritis-associated death in the USA. Adherence to guideline recommendations for treatment of severe C. difficile infection (CDI) is associated with improved clinical success and reduced mortality. The purpose of this study was to determine whether implementation of a pharmacist-led antimicrobial stewardship program (ASP) CDI initiative improved adherence to CDI treatment guidelines and clinical outcomes. This was a single-center, retrospective, quasi-experimental study evaluating patients with CDI before and after implementation of an ASP initiative involving prospective audit and feedback in which guideline-driven treatment recommendations were communicated to treatment teams and documented in the electronic health record via pharmacy progress notes for all patients diagnosed with CDI. The primary endpoint was the proportion of patients treated with guideline adherent definitive regimens within 72 hours of CDI diagnosis. Secondary objectives were to evaluate the impact on clinical outcomes, including length of stay (LOS), infection-related LOS, 30-day readmission rates, and all-cause, in-hospital mortality. A total of 233 patients were evaluated. The proportion of patients on guideline adherent definitive CDI treatment regimen within 72 hours of diagnosis was significantly higher in the post-interventional group (pre: 42% vs post: 58%, p=0.02). No differences were observed in clinical outcomes or proportions of patients receiving laxatives, promotility agents, or proton pump inhibitors within 72 hours of diagnosis. Our findings demonstrate that a pharmacist-led stewardship initiative improved adherence to evidence-based practice guidelines for CDI treatment.

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An evaluation of toxigenic Clostridioides difficile positivity as a patient outcome metric of antimicrobial stewardship in Saudi Arabia

10.1101/2021.02.23.21252226 ◽

2021 ◽

Author(s):

Christopher A. Okeahialam ◽

Ali A. Rabaan ◽

Albert Bolhuis

Keyword(s):

Patient Outcome ◽

Saudi Arabia ◽

Antimicrobial Stewardship ◽

Laboratory Data ◽

Hospitalized Patients ◽

Antimicrobial Stewardship Program ◽

Repeated Testing ◽

Clostridioides Difficile ◽

Stewardship Program ◽

The Impact

AbstractBackgroundAntimicrobial stewardship has been associated with a reduction in the incidence of health care associated Clostridium difficile infection (HA-CDI). However, CDI remains under-recognized in many low and middle-income countries where clinical and surveillance resources required to identify HA-CDI are often lacking. The rate of toxigenic C. difficile stool positivity in the stool of hospitalized patients may offer an alternative metric for these settings, but its utlity remains largely untested.Aim/ObjectiveTo examine the impact of an antimicrobial stewardship on the rate of toxigenic C. difficile positivity among hospitalized patients presenting with diarrhoeaMethodsA 12-year retrospective review of laboratory data was conducted to compare the rates of toxigenic C. difficile in diarrhoea stool of patients in a hospital in Saudi Arabia, before and after implementation of an antimicrobial stewardship programResultThere was a significant decline in the rate of toxigenic C difficile positivity from 9.8 to 7.4% following the implementation of the antimicrobial stewardship program, and a reversal of a rising trend.DiscussionThe rate of toxigenic C. difficile positivity may be a useful patient outcome metric for evaluating the long term impact of antimicrobial stewardship on CDI, especially in settings with limited surveillance resources. The accuracy of this metric is however dependent on the avoidance of arbitrary repeated testing of a patient for cure, and testing only unformed or diarrhoea stool specimens. Further studies are required within and beyond Saudi Arabia to examine the utility of this metric.

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1059. Impact of a Syndrome-Based Antimicrobial Stewardship Intervention on Anti-Pseudomonal β-Lactam Use, C. difficile Rates and Cost in an Urban Community Hospital

Open Forum Infectious Diseases ◽

10.1093/ofid/ofz360.923 ◽

2019 ◽

Vol 6 (Supplement_2) ◽

pp. S374-S375

Author(s):

Alfredo J Mena Lora ◽

Martin Cortez ◽

Ella Li ◽

Lawrence Sanchez ◽

Rochelle Bello ◽

...

Keyword(s):

Antimicrobial Stewardship ◽

Community Hospital ◽

Treatment Guidelines ◽

Urban Community ◽

Audit And Feedback ◽

Evidence Based ◽

Days Of Therapy ◽

Before And After ◽

Prospective Audit And Feedback ◽

The Impact

Abstract Background The use of anti-Pseudomonal β-lactam (APBL) agents has significantly increased in the past decade, carrying higher costs and contributing to antimicrobial pressure. Antimicrobial stewardship (ASP) can promote evidence-based antimicrobial selection and mitigate excess APBL use. We implemented a comprehensive ASP with syndrome-based prospective audit and feedback (PAF) at an urban community hospital. The goal of this study is to assess the impact of syndrome-based PAF on APBL use, C. difficile rates and cost. Methods ASP with all CDC core elements was implemented at a 151-bed community hospital in October 2017. Syndrome-based guidelines and PAF was established and overseen via direct communication with an ID physician. Days of therapy (DOT), cost and C. difficile rates were assessed 12 months before and after ASP. DOT for APBL and non-APBL utilization was tabulated by unit and paired t-test performed. Results Most cases reviewed by PAF (51%) were represented in our syndrome-based treatment guidelines (Figure 1). Soft tissue (33%) and intra-abdominal (24%) infections were the most common syndromes. Change to guideline was the most common PAF intervention (62%) followed by de-escalation (30%). At 12 months, total DOT/1,000 increased (392.5 vs. 404) while the proportion of parenteral antimicrobials used decreased (71% vs. 65%). Antibiotic expenditures decreased by 23%, with a reduction in APBL of 20% and non-APBL of 10% (Table 1). Statistically significant reductions APBL use in non-ICU settings (P = 0.0139) and statistically significant increases in non-APBL in ICU settings occurred (P = 0.0001) (Figure 2 and 3). C difficile rates decreased from 21% (3.27 vs. 2.56). Conclusion Syndrome-based PAF was successfully implemented. A reduction in APBL use was seen in non-ICU settings, where evidence-based de-escalation may be more feasible. APBL use remained high in the ICU but was guideline consistent. A rise in non-APBL use also occurred. Certain critical illness syndromes warrant APBLs, but PAF may promote culture-directed and syndrome-specific treatments. ASP increased guideline-based therapy and contributed to decreased broad-spectrum antimicrobial use, antimicrobial expenditures and C difficile rates. Syndrome based PAF can be successfully implemented in community settings. Disclosures All authors: No reported disclosures.

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1141. Implementation of a Pediatric Handshake Antimicrobial Stewardship Program to Improve Antimicrobial Utilization

Open Forum Infectious Diseases ◽

10.1093/ofid/ofz360.1005 ◽

2019 ◽

Vol 6 (Supplement_2) ◽

pp. S406-S406

Author(s):

Amanda P Hughes ◽

Maya Beganovic ◽

Ronda Oram ◽

Sarah Wieczorkiewicz ◽

Anthony Chiang

Keyword(s):

Antimicrobial Stewardship ◽

Audit And Feedback ◽

Prescribing Practices ◽

Stewardship Program ◽

Antimicrobial Utilization ◽

Days Of Therapy ◽

Significant Difference ◽

Acceptance Rates ◽

Prospective Audit And Feedback ◽

The Impact

Abstract Background Antimicrobial stewardship (AMS) programs emerged in response to rising rates of resistance and adverse effects associated with inappropriate antimicrobial utilization. Optimal metrics and strategies (e.g., preauthorization, prospective audit and feedback) for AMS remain to be elucidated. This study evaluated the impact of a multidisciplinary, rounding-based AMS strategy (i.e., Handshake Stewardship) on antimicrobial utilization and prescribing practices at a pediatric hospital. Methods This was a single-center, retrospective quality improvement study at a community, teaching children’s hospital. All pediatric and neonatal inpatients with active antimicrobial orders between July 2018 and March 2019 were included in the study, and endpoints were compared with data from July 2017- March 2018. Antimicrobial courses were prospectively audited by a multidisciplinary AMS team, and feedback was provided to the primary teams during Handshake Stewardship rounds. The primary endpoint was a number of interventions made and the corresponding acceptance rates. The secondary endpoint was days of therapy (DOT) per 1000 patient-days. Descriptive statistics were performed on all continuous and categorical data as appropriate. Results Of 2238 antimicrobial courses reviewed, 710 (32%) required intervention, and 86% of the interventions made were accepted. The top 3 indications evaluated were respiratory (n = 522, 23%), sepsis/bacteremia (n = 351, 16%), and surgical prophylaxis (n = 266, 12%). Of the respiratory courses reviewed, there were 228 opportunities for antimicrobial optimization. The most common interventions were: bug-drug optimization (n = 208, 29%), discontinuation of anti-infective (n = 136, 19%), and dose optimization (n = 120, 17%). No significant difference was observed for overall, ceftriaxone, meropenem, and vancomycin DOT pre- and post-implementation of Handshake Stewardship. However, a statistically significant reduction in DOTs was observed for piperacillin–tazobactam (15.2 vs. 7.4, P = 0.004) and a nonsignificant reduction in meropenem (9.5 vs. 6.2). Conclusion Rounding-based, Handshake AMS was associated with overall high intervention acceptance rates and a reduction in commonly utilized broad-spectrum antimicrobials. Disclosures All authors: No reported disclosures.

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A Physician-Driven Quality Improvement Stewardship Intervention Using Lean Six Sigma Improves Patient Care for Community-Acquired Pneumonia

Global Journal on Quality and Safety in Healthcare ◽

10.36401/jqsh-21-2 ◽

2021 ◽

Author(s):

Lea M. Monday ◽

Omid Yazdanpaneh ◽

Caleb Sokolowski ◽

Jane Chi ◽

Ryan Kuhn ◽

...

Keyword(s):

Quality Improvement ◽

Clinical Outcomes ◽

Antimicrobial Stewardship ◽

Six Sigma ◽

Intervention Group ◽

Community Acquired Pneumonia ◽

Lean Six Sigma ◽

Audit And Feedback ◽

Control Group ◽

The Impact

ABSTRACT Introduction The Infectious Diseases Society of America (IDSA) recommends a minimum of 5 days of antibiotic therapy in stable patients who have community-acquired pneumonia (CAP). However, excessive duration of therapy (DOT) is common. Define, measure, analyze, improve, and control (DMAIC) is a Lean Six Sigma methodology used in quality improvement efforts, including infection control; however, the utility of this approach for antimicrobial stewardship initiatives is unknown. To determine the impact of a prospective physician-driven stewardship intervention on excess antibiotic DOT and clinical outcomes of patients hospitalized with CAP. Our specific aim was to reduce excess DOT and to determine why some providers treat beyond the IDSA minimum DOT. Methods A single-center, quasi-experimental quality improvement study evaluating rates of excess antimicrobial DOT before and after implementing a DMAIC-based antimicrobial stewardship intervention that included education, prospective audit, and feedback from a physician peer, and daily tracking of excess DOT on a Kaizen board. The baseline period included retrospective CAP cases that occurred between October 2018 and February 2019 (control group). The intervention period included CAP cases between October 2019 and February 2020 (intervention group). Results A total of 123 CAP patients were included (57 control and 66 intervention). Median antibiotic DOT per patient decreased (8 versus 5 days; p < 0.001), and the proportion of patients treated for the IDSA minimum increased (5.3% versus 56%; p < 0.001) after the intervention. No differences in mortality, readmission, length of stay, or incidence of Clostridioides difficile infection were observed between groups. Almost half of the caregivers surveyed were aware that as few as 5 days of antibiotic treatment could be appropriate. Conclusions A physician-driven antimicrobial quality improvement initiative designed using DMAIC methodology led to reduced DOT and increased compliance with the IDSA treatment guidelines for hospitalized patients with CAP reduced without negatively affecting clinical outcomes.

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Impact of California’s mandate for antimicrobial stewardship programs on rates of methicillin-resistant Staphylococcus aureus and Clostridioides difficile infection in acute-care hospitals

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2020.446 ◽

2020 ◽

pp. 1-7

Author(s):

Alessandra B. Garcia Reeves ◽

Sally C. Stearns ◽

Justin G. Trogdon ◽

James W. Lewis ◽

David J. Weber ◽

...

Keyword(s):

Staphylococcus Aureus ◽

Acute Care ◽

Antimicrobial Stewardship ◽

Fixed Effects ◽

Acute Care Hospitals ◽

The United States ◽

Methicillin Resistant ◽

Clostridioides Difficile ◽

Stewardship Program ◽

The Impact

Abstract Objective: To estimate the impact of California’s antimicrobial stewardship program (ASP) mandate on methicillin-resistant Staphylococcus aureus (MRSA) and Clostridioides difficile infection (CDI) rates in acute-care hospitals. Population: Centers for Medicare and Medicaid Services (CMS)–certified acute-care hospitals in the United States. Data Sources: 2013–2017 data from the CMS Hospital Compare, Provider of Service File and Medicare Cost Reports. Methods: Difference-in-difference model with hospital fixed effects to compare California with all other states before and after the ASP mandate. We considered were standardized infection ratios (SIRs) for MRSA and CDI as the outcomes. We analyzed the following time-variant covariates: medical school affiliation, bed count, quality accreditation, number of changes in ownership, compliance with CMS requirements, % intensive care unit beds, average length of stay, patient safety index, and 30-day readmission rate. Results: In 2013, California hospitals had an average MRSA SIR of 0.79 versus 0.94 in other states, and an average CDI SIR of 1.01 versus 0.77 in other states. California hospitals had increases (P < .05) of 23%, 30%, and 20% in their MRSA SIRs in 2015, 2016, and 2017, respectively. California hospitals were associated with a 20% (P < .001) decrease in the CDI SIR only in 2017. Conclusions: The mandate was associated with a decrease in CDI SIR and an increase in MRSA SIR.

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Impact of an antimicrobial stewardship program in the antimicrobial-resistant and prevalence of clostridioides difficile infection and amount of antimicrobial consumed in cancer patients

BMC Research Notes ◽

10.1186/s13104-020-05085-3 ◽

2020 ◽

Vol 13 (1) ◽

Cited By ~ 1

Author(s):

Masoud Mardani ◽

Sara Abolghasemi ◽

Shiva Shabani

Keyword(s):

Antimicrobial Stewardship ◽

Antibiotic Consumption ◽

Multidrug Resistant ◽

Marrow Transplant ◽

Blood Cultures ◽

University Hospital ◽

Clostridioides Difficile ◽

Stewardship Program ◽

Quasi Experimental ◽

The Impact

Abstract Objective The The impact of a hospital antimicrobial stewardship was determined on antimicrobial-resistant, Clostridioides difficile rates and the amount of antimicrobial consumed in cancer patients.The intervention effects of antimicrobial stewardship (ASP) plans in 2017–2018 and 2018–2019 were respectively evaluated among hematology/oncology and bone marrow transplant patients in Ayatollah Taleghani University Hospital, Tehran, Iran. In this interventional quasi-experimental study, the ASP repository was utilized to capture four survey questions encompassed in these immunocompromised patients: amount of antibiotics (meropenem and vancomycin) consumption gr-year, the number of positive Clostridioides difficile infection and multidrug-resistant positive cases in blood cultures. Results The number of MDR cases in the periods of 2017–2018 and 2018–2019 were 145 and 75, respectively (p = 0.011). A significant reduction in all positive blood cultures from 2017–2018 to 2018–2019 was found (p = 0.001). 574 patients admitted to our hospital in these periods of 2017- 2018 and 2018- 2019were assessed for MPM and VMN use. The amounts of MPM prescriptions in 2018–2019 was significantly decreased from 22464 to 17262 g (p = 0.043). The significant reduction in antibiotic consumption, MDR organisms, and CDI can highly promote patients’ health and decreasing medical costs and long-term defects for patients.

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Multilayer Model of Pharmacy Participation in the Antimicrobial Stewardship Program at a Large Academic Medical Center

Hospital Pharmacy ◽

10.1177/0018578717726993 ◽

2017 ◽

Vol 52 (9) ◽

pp. 628-634 ◽

Cited By ~ 3

Author(s):

Yanina Dubrovskaya ◽

Marco R. Scipione ◽

Justin Siegfried ◽

Shin-Pung Jen ◽

Vinh Pham ◽

...

Keyword(s):

Antimicrobial Stewardship ◽

Dose Adjustment ◽

Academic Medical Center ◽

Audit And Feedback ◽

Therapeutic Drug ◽

Antimicrobial Stewardship Program ◽

Hospital Pharmacists ◽

Stewardship Program ◽

Days Of Therapy ◽

The Impact

Purpose: Leveraging pharmacy personnel resources for the purpose of antimicrobial stewardship program (ASP) operations presents a challenging task. We describe our experience integrating all pharmacists into an ASP, and evaluate the impact on ASP interventions, antimicrobial utilization, rate of selected hospital-onset infections and readmission. Summary: During a study period (January 1 to December 31, 2015), a total of 14 552 ASP-related pharmacy interventions were performed (ASP clinical pharmacotherapy specialists [CPS] n = 4025; non-ASP CPS n = 4888; hospital pharmacists n = 5639). Sixty percent of interventions by ASP CPS were initiated utilizing the dedicated ASP phone, and 40% through prospective audit and feedback. Non-ASP CPS performed interventions during bedside rounds (dose adjustment 23%, initiate new or alternative anti-infective 21%, discontinue antibiotic(s) 12%, therapeutic drug monitoring 11%, de-escalation 4%), whereas hospital pharmacists participated at the point of verification (dose adjustment 75%, restricted antibiotic verification 15%, and reporting major drug-drug interactions 4%). The acceptance rate of interventions by providers and clinicians was >90% for all groups. Annual aggregate antimicrobial use decreased by 6.4 days of therapy/1000 patient-days (DOT/1000 PD; P = 1.0). Ceftriaxone use increased by 8.4 DOT/1000 PD ( P = .029) without a significant compensatory increase in the use of antipseudomonal agents. Sustained low rates of hospital-onset Clostridium difficile (CDI) and carbapenem-resistant Enterobacteriaceae (CRE) infections were observed in 2015 compared with the prior year (1.1 and 1.2 cases/1000 PD, 0.2 and 0.1 cases/1000 PD, respectively). Thirty-day readmission rate decreased by 0.6% ( P = .019). Conclusions: Integration of all pharmacists into ASP activities based on the level of patient care and responsibilities is an effective strategy to expand clinical services provided by ASP.

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38. Impact of Antimicrobial Stewardship Interventions on Adherence to Clostridioides difficile Treatment Guidelines

Open Forum Infectious Diseases ◽

10.1093/ofid/ofab466.240 ◽

2021 ◽

Vol 8 (Supplement_1) ◽

pp. S141-S141

Author(s):

Elizabeth Neuner ◽

Tamara Krekel ◽

Michael Durkin ◽

Erik R Dubberke ◽

Kevin Hseuh

Keyword(s):

Antimicrobial Stewardship ◽

Treatment Guidelines ◽

Treatment Guideline ◽

Small Sample ◽

Audit And Feedback ◽

Prospective Audit ◽

Research Support ◽

Post Intervention ◽

Prospective Audit And Feedback ◽

The Impact

Abstract Background Facility-specific treatment guidelines are a priority intervention recommended in the CDC Core Elements of Hospital Antimicrobial Stewardship Programs (ASPs). Our ASP sought to improve adherence to the facility C. difficile infection (CDI) treatment guideline by implementing prospective audit and feedback of CDI cases, changing fidaxomicin from being restricted to Infectious Diseases consult use, to only requiring prospective audit and feedback, and allowing fidaxomicin and oral vancomycin orders only through the order set. This study reviews the impact of these interventions. Methods This single-center retrospective quasi-experimental study evaluated inpatient CDI lab events 3 months pre-intervention (10/1/2019-12/31/2019) and post-intervention (10/14/2020-1/14/2021). Patient and treatment data was evaluated via chart review. The primary outcome was adherence to CDI treatment guideline. ASP intervention types were categorized. Statistical analyses were performed using Chi-squared or Fischer’s exact, where appropriate. Results Baseline characteristics were well matched between the 58 and 70 patients pre and post intervention respectively (Table 1). ASP interventions resulting from the prospective audit and feedback are described in Table 2 and overall acceptance rates were high (88%). Guideline adherence improved significantly from 71% pre to 90% post-intervention (p=0.005). Reasons for non-adherence included vancomycin dose incorrect for the severity of illness (9 pre vs 2 post), inappropriate duration (4 pre vs 0 post), use of combination therapy in non-fulminant disease (5 pre vs 3 post), and not using fidaxomicin for recurrent disease (3 pre vs 2 post). Clinical outcomes pre and post intervention were not different in this small sample size: colectomy 1 (2%) vs 1 (1%) p=1, 60 day all- cause mortality 15 (26%) vs 14 (20%) p=0.43, and CDI recurrence at day 60 9/43 (21%) vs 5/56 (9%) p=0.131. Conclusion A bundle of ASP interventions including prospective audit and feedback of CDI cases improved adherence to facility-specific CDI treatment guidelines. Disclosures Tamara Krekel, PharmD, BCPS, BCIDP, Merck (Speaker’s Bureau) Erik R. Dubberke, MD, MSPH, Ferring (Grant/Research Support)Merck (Consultant)Pfizer (Consultant, Grant/Research Support)Seres (Consultant)Summit (Consultant)

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Impact of an antimicrobial stewardship program in the antimicrobial-resistant and prevalence of clostridioides difficile infection and amount of antimicrobial consumed in cancer patients

10.21203/rs.2.17475/v2 ◽

2020 ◽

Author(s):

Masoud Mardani ◽

Sara Abolghasemi ◽

shiva shabani

Keyword(s):

Antimicrobial Stewardship ◽

Antibiotic Consumption ◽

Multidrug Resistant ◽

Marrow Transplant ◽

Blood Cultures ◽

University Hospital ◽

Clostridioides Difficile ◽

Stewardship Program ◽

Quasi Experimental ◽

The Impact

Abstract Objective: The The impact of a hospital antimicrobial stewardship was determined on antimicrobial-resistant, Clostridioides difficile rates and the amount of antimicrobial consumed in cancer patients.The intervention effects of antimicrobial stewardship (ASP) plans in 2017–2018 and 2018–2019 were respectively evaluated among hematology/oncology and bone marrow transplant patients in Ayatollah Taleghani University Hospital, Tehran, Iran. In this interventional quasi-experimental study, the ASP repository was utilized to capture four survey questions encompassed in these immunocompromised patients: amount of antibiotics (meropenem and vancomycin) consumption gr-year, the number of positive Clostridioides difficile infection and multidrug-resistant positive cases in blood cultures. Results: The number of MDR cases in the periods of 2017–2018 and 2018–2019 were 145 and 75, respectively (p = 0.011). A significant reduction in all positive blood cultures from 2017–2018 to 2018–2019 was found (p = 0.001). 574 patients admitted to our hospital in these periods of 2017- 2018 and 2018- 2019were assessed for MPM and VMN use. The amounts of MPM prescriptions in 2018–2019 was significantly decreased from 22464 to 17262 g (p = 0.043). The significant reduction in antibiotic consumption, MDR organisms, and CDI can highly promote patients’ health and decreasing medical costs and long-term defects for patients.

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Impact of a Carbapenem Antimicrobial Stewardship Program on Patient Outcomes

Antimicrobial Agents and Chemotherapy ◽

10.1128/aac.00736-17 ◽

2017 ◽

Vol 61 (9) ◽

Cited By ~ 10

Author(s):

Valerie Xue Fen Seah ◽

Rina Yue Ling Ong ◽

Ashley Shi Yuan Lim ◽

Chia Yin Chong ◽

Natalie Woon Hui Tan ◽

...

Keyword(s):

Length Of Stay ◽

Clinical Outcomes ◽

Antimicrobial Stewardship ◽

Group Versus ◽

Source Control ◽

Negative Consequences ◽

Defined Daily Doses ◽

Stewardship Program ◽

Compromise Patient Safety ◽

The Impact

ABSTRACT Antimicrobial stewardship programs (ASPs) aim to improve appropriate antimicrobial use. However, concerns of the negative consequences from accepting ASP interventions exist, particularly when deescalation or discontinuation of broad-spectrum antibiotics is recommended. Hence, we sought to evaluate the impact on clinical outcomes when ASP interventions for inappropriate carbapenem use were accepted or rejected by primary providers. We retrospectively reviewed all carbapenem prescriptions deemed inappropriate according to institutional guidelines with ASP interventions between July 2011 and December 2014. Intervention acceptance and outcomes, including carbapenem utilization, length of stay, hospitalization charges, 30-day readmission, and mortality rates were reviewed. Data were analyzed in two groups, one in which physicians accepted all interventions (“accepted”) and one in which interventions were rejected (“rejected”). A total of 158 ASP interventions were made. These included carbapenem discontinuation (35%), change to narrower-spectrum antibiotic (32%), dose optimization (17%), further investigations (including imaging and procalcitonin) (11%), infectious diseases referral (3%), antibiotic discontinuation (other than carbapenem) (1%), and source control (1%). Of 220 unique patients, carbapenem use was inappropriate in 101 (45.9%) patients. A significant reduction in carbapenem utilization was observed in the accepted group versus rejected group (median defined daily doses, 0.224 versus 0.668 per 1,000 patient-days, respectively; P < 0.001). There was a significant reduction in 30-day mortality in the accepted (none) versus rejected group (10 deaths, P = 0.015), but there were no differences in length of stay, hospitalization charge, or 30-day readmission rates. Hypotension was independently associated with mortality in multivariate analysis (odds ratio, 5.25; 95% confidence interval, 1.34 to 20.6). In our institution, acceptance of carbapenem ASP interventions did not compromise patient safety in terms of clinical outcomes while reducing consumption.

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