title: Comparison of prior authorization and prospective audit with feedback for antimicrobial stewardship.
abstract: OBJECTIVE
  Although prior authorization and prospective audit with feedback are both effective antimicrobial stewardship program (ASP) strategies, the relative impact of these approaches remains unclear. We compared these core ASP strategies at an academic medical center.
  
  
  METHODS
  Quasi-experimental study.
  
  
  METHODS
  We compared antimicrobial use during the 24 months before and after implementation of an ASP strategy change. The ASP used prior authorization alone during the preintervention period, June 2007 through May 2009. In June 2009, many antimicrobials were unrestricted and prospective audit was implemented for cefepime, piperacillin/tazobactam, and vancomycin, marking the start of the postintervention period, July 2009 through June 2011. All adult inpatients who received more than or equal to 1 dose of an antimicrobial were included. The primary end point was antimicrobial consumption in days of therapy per 1,000 patient-days (DOT/1,000-PD). Secondary end points included length of stay (LOS).
  
  
  RESULTS
  In total, 55,336 patients were included (29,660 preintervention and 25,676 postintervention). During the preintervention period, both total systemic antimicrobial use (-9.75 DOT/1,000-PD per month) and broad-spectrum anti-gram-negative antimicrobial use (-4.00 DOT/1,000-PD) declined. After the introduction of prospective audit with feedback, however, both total antimicrobial use (+9.65 DOT/1,000-PD per month; P < .001) and broad-spectrum anti-gram-negative antimicrobial use (+4.80 DOT/1,000-PD per month; P < .001) increased significantly. Use of cefepime and piperacillin/tazobactam both significantly increased after the intervention (P = .03). Hospital LOS and LOS after first antimicrobial dose also significantly increased after the intervention (P = .016 and .004, respectively).
  
  
  CONCLUSIONS
  Significant increases in antimicrobial consumption and LOS were observed after the change in ASP strategy.
authors.affiliation: Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Jimish M
authors.initials: JM
authors.lastname: Mehta
authors.forename: Kevin
authors.initials: K
authors.lastname: Haynes
authors.forename: E Paul
authors.initials: EP
authors.lastname: Wileyto
authors.forename: Jeffrey S
authors.initials: JS
authors.lastname: Gerber
authors.forename: Daniel R
authors.initials: DR
authors.lastname: Timko
authors.forename: Steven C
authors.initials: SC
authors.lastname: Morgan
authors.forename: Shawn
authors.initials: S
authors.lastname: Binkley
authors.forename: Neil O
authors.initials: NO
authors.lastname: Fishman
authors.forename: Ebbing
authors.initials: E
authors.lastname: Lautenbach
authors.forename: Theoklis
authors.initials: T
authors.lastname: Zaoutis
mesh_terms: D000046:Academic Medical Centers; D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000900:Anti-Bacterial Agents; D017723:Drug Utilization Review; D030141:Feedback, Psychological; D005260:Female; D006801:Humans; D057970:Inappropriate Prescribing / Q000517:prevention & control* / Q000706:statistics & numerical data; D007902:Length of Stay; D008297:Male; D008485:Medical Audit; D008875:Middle Aged; D010043:Outcome and Process Assessment, Health Care; D010414:Pennsylvania; D015397:Program Evaluation; D011446:Prospective Studies; D055815:Young Adult
chemical_list: D000900:Anti-Bacterial Agents
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