title: Impact of antimicrobial stewardship programme changes on unnecessary double anaerobic coverage therapy.
abstract: BACKGROUND
  Concern has been raised over the practice of unnecessary double anaerobic coverage therapy (DACT) in the hospital setting. However, the incidence of and risk factors for unnecessary DACT are not well studied. On 8 September 2008, the antimicrobial stewardship programme (ASP) at our institution was modified such that several antibiotics, including ampicillin/sulbactam and metronidazole, no longer required pre-approval. We anticipated that this change would increase both unnecessary DACT and target antibiotic consumption.
  
  
  METHODS
  A nested case-control study was conducted to determine the cumulative incidence of and risk factors for unnecessary DACT. Cases were subjects who received unnecessary DACT while controls were subjects who did not receive DACT or who received necessary DACT. Segmented regression analysis was subsequently performed to evaluate the impact of ASP changes on unnecessary DACT and consumption of target antibiotics.
  
  
  RESULTS
  From October 2007 to September 2009, the cumulative incidence of unnecessary DACT was 2.3% [95% confidence interval (CI) 1.7-3.1]. Independent risk factors for unnecessary DACT [adjusted odds ratio (95% CI); P value] included hospitalization on a surgical ward [3.51 (1.03-12.02); P = 0.002], hospitalization on an obstetrics and gynaecology ward [9.07 (2.54-32.40); P = 0.002] and underlying metastatic malignancy [3.18 (1.38-7.09); P = 0.006]. The ASP change was associated with an increase in ampicillin/sulbactam and metronidazole consumption. However, there was no significant impact on unnecessary DACT prescribing.
  
  
  CONCLUSIONS
  Although uncommon, unnecessary DACT is more prevalent in specific services. Future qualitative studies focusing on these specific subgroups would be useful in elucidating this problem more clearly. The ASP changes were not associated with increases in unnecessary DACT.
authors.affiliation: Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine, Philadelphia, PA, USA. pinyo@mail.med.upenn.ed
authors.forename: Pinyo
authors.initials: P
authors.lastname: Rattanaumpawan
authors.forename: Knashawn H
authors.initials: KH
authors.lastname: Morales
authors.forename: Shawn
authors.initials: S
authors.lastname: Binkley
authors.forename: Marie
authors.initials: M
authors.lastname: Synnestvedt
authors.forename: Mark G
authors.initials: MG
authors.lastname: Weiner
authors.forename: Leanne B
authors.initials: LB
authors.lastname: Gasink
authors.forename: Neil O
authors.initials: NO
authors.lastname: Fishman
authors.forename: Ebbing
authors.initials: E
authors.lastname: Lautenbach
mesh_terms: D000667:Ampicillin / Q000008:administration & dosage; D000900:Anti-Bacterial Agents / Q000008:administration & dosage* / Q000627:therapeutic use; D001421:Bacteria, Anaerobic; D001424:Bacterial Infections / Q000188:drug therapy* / Q000382:microbiology; D016022:Case-Control Studies; D004334:Drug Administration Schedule; D016903:Drug Monitoring / Q000379:methods*; D004363:Drug Utilization / Q000706:statistics & numerical data*; D006761:Hospitals; D006801:Humans; D057970:Inappropriate Prescribing / Q000706:statistics & numerical data*; D008795:Metronidazole / Q000008:administration & dosage; D010818:Practice Patterns, Physicians'; D013407:Sulbactam / Q000008:administration & dosage
chemical_list: D000900:Anti-Bacterial Agents; D008795:Metronidazole; D000667:Ampicillin; D013407:Sulbactam