Barriers to Adherence to Antimicrobial Stewardship Postprescription Review and Feedback For Broad-Spectrum Antimicrobial Agents: A Nested Case-Control Study

Akane Takamatsu; Kenta Yao; Shutaro Murakami; Yasuaki Tagashira; Shinya Hasegawa; Hitoshi Honda

doi:10.1093/ofid/ofaa298

Barriers to Adherence to Antimicrobial Stewardship Postprescription Review and Feedback For Broad-Spectrum Antimicrobial Agents: A Nested Case-Control Study

Open Forum Infect Dis. 2020 Jul 17;7(8):ofaa298. doi: 10.1093/ofid/ofaa298. eCollection 2020 Aug.

Authors

Akane Takamatsu^{1

2}, Kenta Yao¹, Shutaro Murakami², Yasuaki Tagashira^{1

2}, Shinya Hasegawa^{1

2}, Hitoshi Honda^{1

2}

Affiliations

¹ Division of Infectious Diseases, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan.
² Department of Infection Control, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan.

Abstract

Background: Postprescription review and feedback (PPRF) is one of the most common strategies in antimicrobial stewardship program (ASP) intervention. However, disagreements between the prescribers and ASP personnel can occur. The aim of the present study was to identify the factors associated with nonadherence to PPRF intervention.

Methods: The present retrospective nested case-control study was performed at a tertiary care center, which has been conducting a once-weekly PPRF for carbapenems and piperacillin/tazobactam since 2014. Nonadherence to ASP recommendations was defined as the failure of the primary care team to modify or stop antimicrobial therapy 72 hours after the issuance of PPRF recommendations. Factors associated with nonadherence to PPRF intervention were identified using multivariate logistic regression analysis.

Results: In total, 2466 instances of PPRF in 1714 cases between April 2014 and September 2019 were found. The nonadherence rate was 5.9%, and 44 cases were found in which carbapenems or piperacillin/tazobactam continued to be used against PPRF recommendations. Factors associated with nonadherence to PPRF recommendations were a previous history of hospitalization within 90 days (adjusted odds ratio [aOR], 2.62; 95% confidence interval [CI], 1.18-5.81) and a rapidly fatal McCabe score at the time of PPRF intervention (aOR, 2.87; 95% CI, 1.18-6.98). A review of the narrative comments in the electronic medical records indicated that common reasons for nonadherence were "the patient was sick" (n = 12; 27.3%) and "the antimicrobial seemed to be clinically effective" (n = 9; 20.5%).

Conclusions: Nonadherence to PPRF recommendations was relatively uncommon at the study institution. However, patients with a severe disease condition frequently continued to receive broad-spectrum antimicrobials against PPRF recommendations. Understanding physicians' cognitive process in nonadherence to ASP recommendations and ASP interventions targeting medical subspecialties caring for severely ill patients is needed to improve ASP.

Keywords: adherence; antimicrobial stewardship program; audit and feedback; broad-spectrum antimicrobials; postprescription review and feedback.