How to save 1 million € and reduce antibiotic resistance cases in one year

Over the last decade, an exponential increase in bacterial resistance has been observed worldwide. No new antibacterial agents are expected to be on the market until 2018 at the earliest. Furthermore, the overall societal costs of antibiotic resistance were estimated to be 1.5 billion €/year in the European Union. Inappropriate use of antibiotics has been shown to be directly related to the increase of bacterial resistances, as well as to significant increases in morbidity and mortality. It is widespread in most health centres, and up to 50% of antibiotic treatments prescribed have been estimated to be incorrect. The generalization of antibiotic misuse is likely to be due to a misbalance between the high level of knowledge required for the appropriate use of antibiotics and the scarce training offered in this respect to the practising clinician. The development of antimicrobial stewardship programmes (ASPs) has been encouraged by scientific societies as an essential measure.

In our hospital, an educational, institutionally supported ASP was developed in 2011. The main activity of the programme consists of a training programme directed towards all antibiotic prescribers in the centre based on counselling interviews. Antimicrobial prescriptions were chosen arbitrarily weekly and counselling interviews by expert clinicians were carried out, using non-restrictive  methodology. The objective of the counselling was to improve the prescribing skills of the interviewed physician rather than to change the antimicrobial treatment. Satisfaction with the interview was assessed using anonymous questionnaires. The appropriateness of antimicrobial prescriptions as well as consumption was assessed prospectively throughout the year. Feedback regarding the correct use of treatments was communicated to each participating department periodically. The improvement in antimicrobial prescription was included among the annual objectives linked to economic incentives in every department.

A total of 1.206 CIs were performed during the first year of the programme. Advice was provided to 388 physicians from every clinical department of the centre. At the initiation of the programme, an overall rate of inappropriate antimicrobial treatments of 53% was observed. The rate of inappropriate prescriptions continuously declined to 26.4% in the fourth trimester. Antimicrobial consumption decreased from 1.150 defined daily doses (DDDs) per 1.000 occupied bed-days in the first trimester to 852 DDDs in the fourth, reflecting a reduction in antimicrobial expenditures of 42%. A 1.012.560 € saving was estimated at the end of the year. A total of 352 satisfaction questionnaires were received and 98% described the advice as positive.

Preliminary analysis also suggest a reduction in bacterial resistance rates for some of the most common hospitalary pathogens while mortality rates did not increase upon reducing antimicrobial consumption. The full assessment of the clinical and epidemiological impact of the programme, however, is scheduled for the end of 2013, 2 years after the initiation of the programme.

These results demonstrate significant benefits of PRIOAM, an institutional, education-based ASP 12 months after its implementation. This programme focused on the training of clinicians in the sensitive use of antimicrobials, and thus was not exclusively targeted towards broad-spectrum or expensive antibiotics. The main strength of our programme lies in the pedagogic approach. This form of intervention has been the key to the programme’s success and its excellent level of acceptance among interviewed clinicians. The institutional support and the involvement of a multidisciplinary team reveal a promising tool to maintain and to continuously improve the appropriate use of antimicrobial prescriptions.

Cisneros JM, Neth O, Gil-Navarro MªV, Lepe JA, Jiménez-Parrilla F, Cordero E, Rodríguez-Hernández MªJ, Amaya-Villar R, Cano J, Gutiérrez A, García-Cabrera E, and Molina J, for the PRIOAM team. Global Impact of an Educational Antimicrobial Stewardship Program on Prescribing Practice in a Tertiary Hospital Center. Clin Microbiol Infect 2013 Feb 27. doi: 10.1111/1469-0691.12191.