Hostname: page-component-669899f699-b58lm Total loading time: 0 Render date: 2025-04-27T15:31:06.675Z Has data issue: false hasContentIssue false
  • English
  • Français

A noninferiority cluster-randomized controlled trial on antibiotic postprescription review and authorization by trained general pharmacists and infectious disease clinical fellows

Part of: WILLIAM JARVIS AWARD RECIPIENTS

Published online by Cambridge University Press:  29 August 2018

Pinyo Rattanaumpawan Open the ORCID record for Pinyo Rattanaumpawan [Opens in a new window] ,
Prasit Upapan  and
Visanu Thamlikitkul
Pinyo Rattanaumpawan*
Affiliation:
Division of Infectious Diseases and Tropical Medicine, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
Prasit Upapan
Affiliation:
Division of Infectious Diseases, Department of Medicine, Faculty of Medicine, Srinakharinwirot University, Bangkok, Thailand
Visanu Thamlikitkul
Affiliation:
Division of Infectious Diseases and Tropical Medicine, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
*
Author for correspondence: Pinyo Rattanaumpawan MD, MSCE, PhD, Division of Infectious Diseases and Tropical Medicine, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglung Road, Bangkoknoi, Bangkok, 10700, Thailand. E-mail: pinyo.rat@mahidol.ac.th
Get access Rights & Permissions [Opens in a new window]

Abstract

Objective

We compared the effectiveness of antibiotic postprescription review and authorization (PPRA) determined by infectious disease (ID) clinical fellows with that of trained general pharmacists.

Methods

We conducted a noninferiority cluster-randomized controlled trial in 6 general medical wards at Siriraj Hospital in Bangkok, Thailand. Three wards were randomly assigned to the intervention (ie, the pharmacist PPRA group), and another 3 wards were assigned to the control (ie, the fellow PPRA group). We enrolled all patients in the study wards who received 1 or more doses of the targeted antibiotics: piperacillin/tazobactam, imipenem/cilastatin, and meropenem. The noninferiority margin was 10% for the favorable clinical response and 1.5 defined daily doses (DDDs) for the targeted antibiotics.

Results

We enrolled 303 patients in the pharmacist PPRA group and 307 patients in the ID fellow PPRA group. The baseline and clinical characteristics were similar in the 2 groups. The difference in the favorable response of patients who received the targeted antibiotics (ie, the pharmacist PPRA group minus the fellow PPRA group) was 5.15% (95% confidence interval [CI], –2.69% to 12.98%); the difference in the DDD of targeted antibiotic use (ie, the pharmacist PPRA group minus the fellow PPRA group) was 0.62 (95% CI, –1.57 to 2.82). We observed no significant difference in the DDD of overall antibiotics, 28-day mortality, 28-day ID-related mortality, favorable microbiological outcome, or antibiotic-associated complications.

Conclusions

We confirmed the noninferiority of pharmacist PPRA in terms of favorable clinical response; however, noninferiority in targeted antibiotic consumption could not be established. Therefore, using trained general pharmacists rather than ID clinical fellows could be an alternative in a resource-limited setting.

Clinical trials registration: clinicaltrials.gov identifier: NCT 01797133

Type
Original Article
Information
Infection Control & Hospital Epidemiology , Volume 39 , Issue 10 , October 2018 , pp. 1154 - 1162
Copyright
© 2018 by The Society for Healthcare Epidemiology of America. All rights reserved 

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

Article purchase

Temporarily unavailable

References

1. Safdar, N, Maki, DG. The commonality of risk factors for nosocomial colonization and infection with antimicrobial-resistant Staphylococcus aureus, Enterococcus, gram-negative bacilli, Clostridium difficile, and Candida . Ann Intern Med 2002;136:834–844.Google Scholar
2. Bhavnani, SM, Callen, WA, Forrest, A, et al. Effect of fluoroquinolone expenditures on susceptibility of Pseudomonas aeruginosa to ciprofloxacin in US hospitals. Am J Health Syst Pharm 2003;60:1962–1970.Google Scholar
3. Worth, LJ, Thursky, KA, Seymour, JF, et al. Vancomycin-resistant Enterococcus faecium infection in patients with hematologic malignancy: patients with acute myeloid leukemia are at high-risk. Eur J Haematol 2007;79:226–233.Google Scholar
4. Valiquette, L, Cossette, B, Garant, MP, et al. Impact of a reduction in the use of high-risk antibiotics on the course of an epidemic of Clostridium difficile-associated disease caused by the hypervirulent NAP1/027 strain. Clin Infect Dis 2007;45 Suppl 2:S112–S121.Google Scholar
5. Jeon, MH, Choi, SH, Kwak, YG, et al. Risk factors for the acquisition of carbapenem-resistant Escherichia coli among hospitalized patients. Diagn Microbiol Infect Dis 2008;62:402–406.Google Scholar
6. Owens, RC Jr, Rice, L. Hospital-based strategies for combating resistance. Clin Infect Dis 2006;42 Suppl 4:S173–S181.Google Scholar
7. Freedman, K, Kolluri, B, Neudecker, L. Antimicrobial stewardship stabilizes resistance patterns in a behavioral health setting. Conn Med 2007;71:457–460.Google Scholar
8. Patel, D, Lawson, W, Guglielmo, BJ. Antimicrobial stewardship programs: interventions and associated outcomes. Expert Rev Anti Infect Ther 2008;6:209–222.Google Scholar
9. Davey, P, Brown, E, Fenelon, L, et al. Systematic review of antimicrobial drug prescribing in hospitals. Emerg Infect Dis 2006;12:211–216.Google Scholar
10. Schuts, EC, Hulscher, M, Mouton, JW, et al. Current evidence on hospital antimicrobial stewardship objectives: a systematic review and meta-analysis. Lancet Infect Dis 2016;16:847–856.Google Scholar
11. Barlam, TF, Cosgrove, SE, Abbo, LM, et al. Implementing an antibiotic stewardship program: guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. Clin Infect Dis 2016;62:e51–e77.Google Scholar
12. Rattanaumpawan, P, Sutha, P, Thamlikitkul, V. Effectiveness of drug use evaluation and antibiotic authorization on patients’ clinical outcomes, antibiotic consumption, and antibiotic expenditures. Am J Infect Control 2010;38:38–43.Google Scholar
13. Tamma, PD, Avdic, E, Keenan, JF, et al. What is the more effective antibiotic stewardship intervention: preprescription authorization or postprescription review with feedback? Clin Infect Dis 2017;64:537–543.Google Scholar
14. Gross, R, Morgan, AS, Kinky, DE, et al. Impact of a hospital-based antimicrobial management program on clinical and economic outcomes. Clin Infect Dis 2001;33:289–295.Google Scholar
15. Rybak, MJ. Antimicrobial stewardship. Pharmacotherapy 2007; 27:131S–135S.Google Scholar
16. Moody, J, Cosgrove, SE, Olmsted, R, et al. Antimicrobial stewardship: a collaborative partnership between infection preventionists and healthcare epidemiologists. Infect Control Hosp Epidemiol 2012;33:328–330.Google Scholar
17. Dellit, TH, Owens, RC, McGowan, JE Jr, et al. Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clin Infect Dis 2007;44:159–177.Google Scholar