title: Hospital-wide rollout of antimicrobial stewardship: a stepped-wedge randomized trial.
abstract: Our objective was to rigorously evaluate the impact of an antimicrobial stewardship audit-and-feedback intervention, via a stepped-wedge randomized trial. An effective intensive care unit (ICU) audit-and-feedback program was rolled out to 6 non-ICU services in a randomized sequence. The primary outcome was targeted antimicrobial utilization, using a negative binomial regression model to assess the impact of the intervention while accounting for secular and seasonal trends. The intervention was successfully transitioned, with high volumes of orders reviewed, suggestions made, and recommendations accepted. Among patients meeting stewardship review criteria, the intervention was associated with a large reduction in targeted antimicrobial utilization (-21%, P = .004); however, there was no significant change in targeted antibiotic use among all admitted patients (-1.2%, P = .9), and no reductions in overall costs and microbiologic outcomes. An ICU day 3 audit-and-feedback program can be successfully expanded hospital-wide, but broader benefits on non-ICU wards may require interventions earlier in the course of treatment.
authors.affiliation: Department of Pharmacy, Sunnybrook Health Sciences Centre.
authors.forename: Lesley
authors.initials: L
authors.lastname: Palmay
authors.affiliation: Department of Pharmacy, Sunnybrook Health Sciences Centre.
authors.forename: Marion
authors.initials: M
authors.lastname: Elligsen
authors.affiliation: Department of Pharmacy, Sunnybrook Health Sciences Centre Leslie L. Dan Faculty of Pharmacy, University of Toronto Department of Microbiology and Division of Infectious Diseases, Sunnybrook Health Sciences Centre.
authors.forename: Sandra A N
authors.initials: SA
authors.lastname: Walker
authors.affiliation: Trauma, Emergency and Critical Care Program, Sunnybrook Health Sciences Center.
authors.forename: Ruxandra
authors.initials: R
authors.lastname: Pinto
authors.affiliation: Department of Pharmacy, Sunnybrook Health Sciences Centre Leslie L. Dan Faculty of Pharmacy, University of Toronto.
authors.forename: Scott
authors.initials: S
authors.lastname: Walker
authors.affiliation: Leslie L. Dan Faculty of Pharmacy, University of Toronto.
authors.forename: Thomas
authors.initials: T
authors.lastname: Einarson
authors.affiliation: Department of Microbiology and Division of Infectious Diseases, Sunnybrook Health Sciences Centre Faculty of Medicine, University of Toronto.
authors.forename: Andrew
authors.initials: A
authors.lastname: Simor
authors.affiliation: Department of Microbiology and Division of Infectious Diseases, Sunnybrook Health Sciences Centre Faculty of Medicine, University of Toronto.
authors.forename: Anita
authors.initials: A
authors.lastname: Rachlis
authors.affiliation: Department of Microbiology and Division of Infectious Diseases, Sunnybrook Health Sciences Centre Faculty of Medicine, University of Toronto Sunnybrook Research Institute.
authors.forename: Samira
authors.initials: S
authors.lastname: Mubareka
authors.affiliation: Department of Microbiology and Division of Infectious Diseases, Sunnybrook Health Sciences Centre Faculty of Medicine, University of Toronto Sunnybrook Research Institute Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.
authors.forename: Nick
authors.initials: N
authors.lastname: Daneman
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000890:Anti-Infective Agents / Q000627:therapeutic use*; D004363:Drug Utilization / Q000191:economics / Q000592:standards*; D005260:Female; D005500:Follow-Up Studies; D006761:Hospitals; D006801:Humans; D007362:Intensive Care Units; D008297:Male; D008485:Medical Audit; D008875:Middle Aged; D016032:Randomized Controlled Trials as Topic; D016896:Treatment Outcome
chemical_list: D000890:Anti-Infective Agents
keywords: antimicrobial stewardship; prospective audit and feedback; quality improvement; stepped-wedge randomized trial