title: What Is the More Effective Antibiotic Stewardship Intervention: Preprescription Authorization or Postprescription Review With Feedback?
abstract: The optimal approach to conducting antibiotic stewardship interventions has not been defined. We compared days of antibiotic therapy (DOT) using preprescription authorization (PPA) vs postprescription review with feedback (PPRF) strategies.
  
  
  
  A quasi-experimental, crossover trial comparing PPA and PPRF for adult inpatients prescribed any antibiotic was conducted. For the first 4 months, 2 medicine teams were assigned to the PPA arm and the other 2 teams to the PPRF arm. The teams were then assigned to the alternate arm for an additional 4 months. Appropriateness of antibiotic use was adjudicated by at least 2 infectious diseases-trained clinicians and according to institutional guidelines.
  
  
  
  There were 2686 and 2693 patients admitted to the PPA and PPRF groups, with 29% and 27% of patients prescribed antibiotics, respectively. Initially, antibiotic DOTs remained relatively unchanged in the PPA arm. When changed to the PPRF arm, antibiotic use decreased (-2.45 DOT per 1000 patient-days [PD]). In the initial PPRF arm, antibiotic use decreased (slope of -5.73 DOT per 1000 PD) but remained constant when changed to the PPA arm. Median patient DOTs in the PPA and PPRF arms were 8 and 6 DOT per 1000 PD, respectively (P = .03). Antibiotic therapy was guideline-noncompliant in 34% and 41% of patients on days 1 and 3 in the PPA group (P < .01) and in 57% and 36% of patients on days 1 and 3 in the PPRF group (P = .03).
  
  
  
  PPRF may have more of an impact on decreasing antibiotic DOTs compared with PPA. This information may be useful for institutions without sufficient resources to incorporate both stewardship approaches.
authors.affiliation: Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
authors.forename: Pranita D
authors.initials: PD
authors.lastname: Tamma
authors.affiliation: Department of Pharmacy, Johns Hopkins Hospital, Baltimore, Maryland, USA.
authors.forename: Edina
authors.initials: E
authors.lastname: Avdic
authors.affiliation: Department of Family Medicine, Lynchburg General and Virginia Baptist Hospital, Lynchburg, USA.
authors.forename: John F
authors.initials: JF
authors.lastname: Keenan
authors.affiliation: Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.
authors.forename: Yuan
authors.initials: Y
authors.lastname: Zhao
authors.affiliation: Division of Gastroenterology, Department of Medicine, University of California, San Diego, USA.
authors.forename: Gobind
authors.initials: G
authors.lastname: Anand
authors.affiliation: Division of Hematology, Department of Medicine, National Institutes of Health, Bethesda, MD, USA.
authors.forename: James
authors.initials: J
authors.lastname: Cooper
authors.affiliation: Pulmonary and Critical Care Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA.
authors.forename: Rebecca
authors.initials: R
authors.lastname: Dezube
authors.affiliation: Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
authors.forename: Steven
authors.initials: S
authors.lastname: Hsu
authors.affiliation: Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
authors.forename: Sara E
authors.initials: SE
authors.lastname: Cosgrove
mesh_terms: D000368:Aged; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D000073602:Antimicrobial Stewardship; D001424:Bacterial Infections / Q000150:complications / Q000188:drug therapy / Q000382:microbiology; D000066491:Clinical Decision-Making; D015897:Comorbidity; D011307:Drug Prescriptions / Q000592:standards; D017723:Drug Utilization Review; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D013997:Time Factors
chemical_list: D000900:Anti-Bacterial Agents
keywords: ASP; antibiotics; antimicrobial stewardship.; days of therapy