title: Decreased antimicrobial resistance and defined daily doses after implementation of a clinical culture-guided antimicrobial stewardship program in a local hospital.
abstract: BACKGROUND
  We aimed to report the implementation of an antimicrobial stewardship program (ASP) guided by clinically significant cultures in a hospital to assess its pharmaceutical, microbiological, financial, and outcome effects.
  
  
  METHODS
  A 3-year cohort study of an antimicrobial restriction policy implementation was performed. The ASP with culture-guided de-escalation of antibiotics was instituted in a local hospital since January 1, 2012. The cost of antimicrobials, defined daily dose (DDD), susceptibility to antimicrobials, and outcome of all admitted patients were calculated and evaluated before and after the ASP implementation.
  
  
  RESULTS
  Average monthly length of stay of admitted patients decreased from 7.8 ± 0.5 days in 2011 to 6.9 ± 0.3 days in 2013 (p < 0.001). The average monthly cost of antimicrobials decreased 46.9% from US$30,146.8 in 2011 to US$16,021.3 in 2013 (p < 0.001). Total intravenous antimicrobial DDDs per 100 bed-days of the inpatients were 66.9, 54.1 and 48.4 in 2011, 2012 and 2013, respectively. A total of 18.6 DDDs per 100 bed-days of inpatients (27.7%) decreased from 2011 to 2013. By comparing data in 2013 to those in 2011, the ASP reduced antimicrobial resistance of Gram-positive bacteria (p = 0.013), Gram-negative bacteria (p < 0.001), and predominant species (all p < 0.05). The yearly mortality also decreased from 1.3% in 2011 to 1.1% in 2012 and 1.0% in 2013.
  
  
  CONCLUSIONS
  The ASP with a culture-guided de-escalation of antibiotics successfully reduced length of stay, mortality, the cost of antimicrobials, DDDs, and antimicrobial resistance rate, and that is highly recommended for local hospitals.
authors.affiliation: Division of Pediatric General Medicine, Chang Gung Children's Hospital, Taoyuan, Taiwan; Graduate Institute of Clinical Medical Sciences, Chang Gung University College of Medicine, Taoyuan, Taiwan.
authors.forename: Chang-Teng
authors.initials: CT
authors.lastname: Wu
authors.affiliation: Molecular Infectious Disease Research Center, Department of Medical Research, Chang Gung Memorial Hospital, Taoyuan, Taiwan.
authors.forename: Chyi-Liang
authors.initials: CL
authors.lastname: Chen
authors.affiliation: Department of Nursing, Jen-Teh Junior College of Medicine, Nursing and Management, Miaoli, Taiwan; Division of Pediatric General Medicine, Chang Gung Children's Hospital, Taoyuan, Taiwan; Graduate Institute of Clinical Medical Sciences, Chang Gung University College of Medicine, Taoyuan, Taiwan; Molecular Infectious Disease Research Center, Department of Medical Research, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Department of Infection Control, Pharmacy and Microbiology, Nan Men General Hospital, Hsinchu, Taiwan; Department of Pediatrics, Wei-Gong Memorial Hospital, Miaoli, Taiwan. Electronic address: d9700101@gmail.com.
authors.forename: Hao-Yuan
authors.initials: HY
authors.lastname: Lee
authors.affiliation: Division of Pediatric General Medicine, Chang Gung Children's Hospital, Taoyuan, Taiwan; Graduate Institute of Clinical Medical Sciences, Chang Gung University College of Medicine, Taoyuan, Taiwan.
authors.forename: Chee-Jen
authors.initials: CJ
authors.lastname: Chang
authors.affiliation: Department of Infection Control, Pharmacy and Microbiology, Nan Men General Hospital, Hsinchu, Taiwan.
authors.forename: Pi-Yu
authors.initials: PY
authors.lastname: Liu
authors.affiliation: Department of Infection Control, Pharmacy and Microbiology, Nan Men General Hospital, Hsinchu, Taiwan.
authors.forename: Chin-Ying
authors.initials: CY
authors.lastname: Li
authors.affiliation: Department of Infection Control, Pharmacy and Microbiology, Nan Men General Hospital, Hsinchu, Taiwan.
authors.forename: Ming-Ying
authors.initials: MY
authors.lastname: Liu
authors.affiliation: Department of Infection Control, Pharmacy and Microbiology, Nan Men General Hospital, Hsinchu, Taiwan.
authors.forename: Chien-Hsisung
authors.initials: CH
authors.lastname: Liu
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000900:Anti-Bacterial Agents / Q000191:economics / Q000627:therapeutic use*; D000073602:Antimicrobial Stewardship / Q000379:methods*; D002648:Child; D015331:Cohort Studies; D017281:Cost of Illness; D024881:Drug Resistance, Bacterial / Q000502:physiology; D005260:Female; D006090:Gram-Negative Bacteria / Q000187:drug effects; D016905:Gram-Negative Bacterial Infections / Q000188:drug therapy* / Q000453:epidemiology / Q000382:microbiology; D006094:Gram-Positive Bacteria / Q000187:drug effects; D016908:Gram-Positive Bacterial Infections / Q000188:drug therapy* / Q000453:epidemiology / Q000382:microbiology; D017052:Hospital Mortality / Q000639:trends; D006761:Hospitals; D006801:Humans; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D011795:Surveys and Questionnaires; D016896:Treatment Outcome; D055815:Young Adult
chemical_list: D000900:Anti-Bacterial Agents
keywords: antimicrobial resistance; antimicrobial restriction policy; antimicrobial stewardship program; defined daily dose