Assessment of the Appropriateness of Antimicrobial Use in US Hospitals

Abstract

Importance: Hospital antimicrobial consumption data are widely available; however, large-scale assessments of the quality of antimicrobial use in US hospitals are limited.

Objective: To evaluate the appropriateness of antimicrobial use for hospitalized patients treated for community-acquired pneumonia (CAP) or urinary tract infection (UTI) present at admission or for patients who had received fluoroquinolone or intravenous vancomycin treatment.

Design, setting, and participants: This cross-sectional study included data from a prevalence survey of hospitalized patients in 10 Emerging Infections Program sites. Random samples of inpatients on hospital survey dates from May 1 to September 30, 2015, were identified. Medical record data were collected for eligible patients with 1 or more of 4 treatment events (CAP, UTI, fluoroquinolone treatment, or vancomycin treatment), which were selected on the basis of common infection types reported and antimicrobials given to patients in the prevalence survey. Data were analyzed from August 1, 2017, to May 31, 2020.

Exposure: Antimicrobial treatment for CAP or UTI or with fluoroquinolones or vancomycin.

Main outcomes and measures: The percentage of antimicrobial use that was supported by medical record data (including infection signs and symptoms, microbiology test results, and antimicrobial treatment duration) or for which some aspect of use was unsupported. Unsupported antimicrobial use was defined as (1) use of antimicrobials to which the pathogen was not susceptible, use in the absence of documented infection signs or symptoms, or use without supporting microbiologic data; (2) use of antimicrobials that deviated from recommended guidelines; or (3) use that exceeded the recommended duration.

Results: Of 12 299 patients, 1566 patients (12.7%) in 192 hospitals were included; the median age was 67 years (interquartile range, 53-79 years), and 864 (55.2%) were female. A total of 219 patients (14.0%) were included in the CAP analysis, 452 (28.9%) in the UTI analysis, 550 (35.1%) in the fluoroquinolone analysis, and 403 (25.7%) in the vancomycin analysis; 58 patients (3.7%) were included in both fluoroquinolone and vancomycin analyses. Overall, treatment was unsupported for 876 of 1566 patients (55.9%; 95% CI, 53.5%-58.4%): 110 of 403 (27.3%) who received vancomycin, 256 of 550 (46.6%) who received fluoroquinolones, 347 of 452 (76.8%) with a diagnosis of UTI, and 174 of 219 (79.5%) with a diagnosis of CAP. Among patients with unsupported treatment, common reasons included excessive duration (103 of 174 patients with CAP [59.2%]) and lack of documented infection signs or symptoms (174 of 347 patients with UTI [50.1%]).

Conclusions and relevance: The findings suggest that standardized assessments of hospital antimicrobial prescribing quality can be used to estimate the appropriateness of antimicrobial use in large groups of hospitals. These assessments, performed over time, may inform evaluations of the effects of antimicrobial stewardship initiatives nationally.

Conflict of interest statement

Conflict of Interest Disclosures: Dr Kainer reported receiving nonfinancial support from the Council of State and Territorial Epidemiologists, the Society for Healthcare Epidemiology of America (SHEA), the American Society for Microbiology, and the Public Health Association of Australia; receiving personal fees from Infectious Diseases Cindukting Corporation; and receiving personal fees and nonfinancial support from the Infectious Disease Consulting Corporation (IDCC), WebMD, and Pfizer outside the submitted work. Dr Bamberg reported grants from the Centers for Disease Control and Prevention (CDC) to the Colorado Department of Public Health and Environment during the conduct of the study. Dr Johnston reported receiving grants from CDC to the Colorado Department of Public Health and Environment during the conduct of the study. Ms Janelle reported receiving grants from CDC during the conduct of the study. Dr Lynfield reported receiving grants from CDC Emerging Infections Cooperative Agreement during the conduct of the study and being co-editor and receiving royalties for a book from the American Academy of Pediatrics, which were donated to the Minnesota Department of Health, outside the submitted work. Ms Warnke reported receiving grants from the CDC during the conduct of the study. Ms Nadle reported receiving grants from the CDC Emerging Infections Program Cooperative Agreement outside the submitted work. Dr Thompson reported receiving grants from CDC Emerging Infections Program during the conduct of the study. Dr Pierce reported receiving grants from CDC Emerging Infection Program and the CDC Epidemiology and Laboratory Capacity during the conduct of the study and personal fees from SHEA outside the submitted work. Ms Zhang reported receiving grants from the CDC during the conduct of the study. Ms Maloney reported receiving grants from the CDC Emerging Infections Program Cooperative Agreement during the conduct of the study and receiving a SHEA Education & Research Foundation Public Health Scholarship. Dr Wilson reported receiving grants from the CDC to the Maryland Department of Health. Dr Dumyati reported receiving grants from the CDC and personal fees from Roche Molecular Diagnostics during the conduct of the study and from Seres Therapeutics outside the submitted work. No other disclosures were reported.