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Improving Antimicrobial Use at a University Hospital: Results of the First Five Years of a Multidisciplinary Antimicrobial Management Program

Craig Martin, Pharm.D., Robert Rapp, Pharm.D., Martin Evans, M.D., Ardis Hoven, M.D., John Armistead, M.S., FSHP

 

University of Kentucky Chandler Medical Center
Lexington, Kentucky

 

Purpose

Antimicrobial control programs have been advocated in response to inappropriate use and increasing antimicrobial resistance among nosocomial pathogens, as well as escalating costs of antimicrobial agents. During the mid-1990s, physicians in infectious disease and clinical pharmacists at our institution were becoming concerned about the increasing resistance rates of key pathogens to commonly used antibiotics and the steady increase in the pharmacy department’s annual expenditures for anti-infective agents. These concerns led to a series of initiatives aimed at controlling antimicrobial use for the purpose of minimizing the development of antibiotic resistance in nosocomial pathogens and reducing cost. We report the results of the first five years (1998-2002) of an ongoing antimicrobial control program in our institution.

Description of the Program

We initiated a formal antimicrobial control program at the University of Kentucky Chandler Medical Center in 1998 with the formation of a multidisciplinary antimicrobial subcommittee of the pharmacy and therapeutics committee. Members of the subcommittee included representatives from the disciplines of surgery, pediatrics, internal medicine, transplant, critical care, infectious diseases, pharmacy, and nursing. The antimicrobial subcommittee was charged with the following responsibilities: (1) to develop and implement initiatives to ensure the appropriate use of antimicrobial agents by physicians in our institution and (2) to review the existing formulary with the goal of recommending more cost-effective antimicrobial choices that would also reduce the selection of resistant nosocomial pathogens. Key interventions included removal of ceftazidime and cefotaxime from the formulary, introduction of cefepime and a combination product containing piperacillin sodium and tazobactam sodium to the formulary, restriction of vancomycin and carbapenem use, and selection of a single fluoroquinolone agent. Subsequently, our institution was able to justify the cost of hiring a pharmacist (1.0 FTE) and physician (0.5 FTE) to lead this program.

Experience with the Program

Antimicrobial use was reduced by 80% for third-generation cephalosporins and 15% for vancomycin following the implementation of the new antimicrobial policies. Antimicrobial resistance patterns for many important gram-negative pathogens, including Pseudomonas aeruginosa, demonstrated a reversal of previous increases. In addition, the rate of methicillin-resistant Staphylococcus aureus was reduced an average of 3% each year from 1999 to 2002. Pharmacy expenditures decreased 24.7% for all antimicrobial agents, including antiviral, antifungal, and antibacterial agents, with a cumulative cost savings of $1,401,126, without inflation assumptions. When a 10% inflation rate is assumed, these cost savings escalate to $4,438,825.

Conclusion

A well-designed antimicrobial management program and team has improved resistance rates in selected pathogens and resulted in substantial cost savings at our institution.