3159 — Antimicrobial Stewardship Programs in Inpatient Hospital Settings: A Systematic Review

Filice G, Minneapolis VA Health Care System; Drekonja D, Minneapolis VA Health Care System; Greer N, Minneapolis VA Health Care System; MacDonald R, Minneapolis VA Health Care System; Rutks I, Minneapolis VA Health Care System; Wagner B, Minneapolis VA Health Care System; Butler M, University of Minnesota; Wilt TJ, Minneapolis VA Health CareSystem;

Objectives:
Systematically review evidence for effectiveness of antimicrobial stewardship programs (ASPs) implemented in hospital settings.

Methods:
We searched MEDLINE (2000 through June 2013), the Cochrane Library, and reference lists of relevant studies and systematic reviews and included English language studies enrolling patient populations relevant to the United States (ie, infectious conditions, prescription services), with a control or pre-intervention group, evaluating ASP interventions, and reporting outcomes of interest. We excluded studies reported in a recent Cochrane review that partially addressed our key questions. Investigators and trained research personnel extracted study characteristics; patient, prescribing, and microbial outcomes; and harms. We assessed risk of bias of individual studies and rated strength of evidence for patient outcomes.

Results:
Thirty-five studies met eligibility criteria. Most studies were conducted at university-affiliated or teaching hospitals. Strength of evidence was low for mortality, length of stay, readmission, and incidence of Clostridium difficile infection for all intervention types (ie, audit and feedback, formulary restriction or preauthorization, guideline implementation, computerized decision support, protocols, or laboratory testing to guide prescribing). Interventions were generally associated with improved prescribing patterns (ie, decreased antimicrobial use or increased appropriate use). There were limited data on microbial outcomes (ie, institutional resistance patterns and resistance in the study population), harms, scalability or sustainability of interventions, key intervention components, or barriers to implementation. Studies were typically of short duration, high risk of bias, and varied in study design, population, site of intervention (ie, intensive care, medical wards), intervention characteristics and implementation, control group, and specific outcomes.

Implications:
There is evidence that ASPs can improve prescribing and microbial outcomes without significant adverse impact on patient outcomes. The effect on mortality or other clinical outcomes is unclear as studies were not designed to assess those outcomes. We urge ongoing evaluation and communication with ASP leaders to determine the efficacy and effect sizes of ASP interventions at individual institutions and across large regional or national healthcare systems.

Impacts:
The VA Antimicrobial Stewardship Task Force has worked closely with the VA Office of Research and Development to develop a solid evidence-base for new practices and policies.