title: Multifaceted intervention to optimize antibiotic use for intra-abdominal infections.
abstract: OBJECTIVE
  Implementing evidence-based practice guidelines is challenging. We used a multifaceted, continuous educational approach to disseminate an up-to-date internal guideline adapted from published guidelines for management of intra-abdominal infections (IAI).
  
  
  METHODS
  The intervention consisted of continuing educational sessions, internal guideline pocket cards and posters with collaboration among all key stakeholders starting in December 2010. We emphasized risk stratification and the use of ceftriaxone/metronidazole for treatment of low-risk IAI, and discouraged the use of fluoroquinolones due to the high local resistance rates. We then compared patients with IAI before the intervention (April-November 2010) to those after implementation of the guideline (April-November 2011) in a surgical unit at a tertiary care teaching hospital in Hamilton, Ontario, Canada. Antibiotic use was measured in in-hospital days of antibiotic therapy (DOT) per 1000 patient days (PD).
  
  
  RESULTS
  152 and 145 patients with IAI were included in the pre- and post-intervention periods, respectively. There was a significant reduction in the proportion of patients who received ciprofloxacin therapy from 74% to 34% (OR 0.18, 95% CI 0.11-0.31) and in DOT/1000 PD from 221 to 74 (OR 0.3, 95% CI 0.2-0.3). Also, a reduction in the DOT/1000 PD for piperacillin/tazobactam was seen (from 116 to 67; OR 0.6, 95% CI 0.5-0.7). There was an increase in the use of ceftriaxone from 1.3% to 53% of patients (OR 85, 95% CI 20-515) and from 6 to 92 DOT/1000 PD (OR 17, 95% CI 10-25). This change in practice was sustained over >2 years since the end of the active intervention, as shown in the unit-wide antimicrobial utilization data.
  
  
  CONCLUSIONS
  A multifaceted intervention aimed at all key stakeholders resulted in a high adherence to evidence-based treatment guidelines for IAI and has initiated a sustained culture change in prescribing of antibiotics.
authors.affiliation: Hamilton Health Sciences, Hamilton, ON, Canada London Health Sciences, London, ON, Canada.
authors.forename: Zagorka
authors.initials: Z
authors.lastname: Popovski
authors.affiliation: Department of Medicine, Division of Cardiology, Columbia University, New York, NY, USA Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada.
authors.forename: Mathew
authors.initials: M
authors.lastname: Mercuri
authors.affiliation: Hamilton Health Sciences, Hamilton, ON, Canada Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada.
authors.forename: Cheryl
authors.initials: C
authors.lastname: Main
authors.affiliation: Hamilton Health Sciences, Hamilton, ON, Canada Department of Surgery, McMaster University, Hamilton, ON, Canada.
authors.forename: Niv
authors.initials: N
authors.lastname: Sne
authors.affiliation: Hamilton Health Sciences, Hamilton, ON, Canada Integrated Pharmacy Services, Women's College Hospital, Toronto, ON, Canada.
authors.forename: Kate
authors.initials: K
authors.lastname: Walsh
authors.affiliation: Hamilton Health Sciences, Hamilton, ON, Canada Department of Medicine, McMaster University, Hamilton, ON, Canada.
authors.forename: Melani
authors.initials: M
authors.lastname: Sung
authors.affiliation: Department of Surgery, McMaster University, Hamilton, ON, Canada.
authors.forename: Timothy
authors.initials: T
authors.lastname: Rice
authors.affiliation: Hamilton Health Sciences, Hamilton, ON, Canada Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada Department of Medicine, McMaster University, Hamilton, ON, Canada Michael G. DeGroote Institute for Infectious Disease Research, Hamilton, ON, Canada mertzd@mcmaster.ca.
authors.forename: Dominik
authors.initials: D
authors.lastname: Mertz
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D001521:Behavior Therapy / Q000379:methods*; D003131:Combined Modality Therapy; D004358:Drug Therapy / Q000592:standards; D004363:Drug Utilization / Q000592:standards; D004502:Education, Medical, Continuing / Q000379:methods*; D005260:Female; D019983:Guideline Adherence; D017408:Guidelines as Topic; D006801:Humans; D059413:Intraabdominal Infections / Q000188:drug therapy*; D008297:Male; D008875:Middle Aged; D009864:Ontario; D062606:Tertiary Care Centers
chemical_list: D000900:Anti-Bacterial Agents
keywords: antimicrobial stewardship; culture; fluoroquinolones; knowledge translation