What is the Optimal Antimicrobial Stewardship Strategy: Pre-Prescription Authorization or Post-Prescription Review and Feedback?

Although antimicrobial stewardship programs (ASP) have been successful in improving antimicrobial prescribing and reducing antimicrobial use, the best method for modifying antimicrobial prescription habits of healthcare workers has not been established. Specifically, there have been no head-to-head comparisons of the two most common approaches to stewardship interventions: pre-prescription authorization (PPA), where the prescriber must obtain permission and advice from the stewardship program prior to release of the first dose of antimicrobials, and post-prescription review and feedback (PPRF), where the provider can choose any empiric antimicrobial regimen but the stewardship team reviews the selected antimicrobials 48-72 hours after they were started and provides advice to the prescriber at that time.

The overall goal of this proposal is to determine which of these two approaches has the greatest impact on appropriate antimicrobial prescribing and clinical outcomes. This goal will be reached via the following key objectives:

1.To assess the impact of pre-prescription authorization (PPA) compared to post-prescription review and feedback (PPRF) on antimicrobial use as measured by (a) overall antimicrobial use; (b) appropriate antimicrobial use both when antimicrobials are started and at 48-72 hours; and (c) excess days of therapy.
2.To assess the impact of PPA compared to PPRF on the clinical outcomes as measured by (a) length of hospitalization, (b) rates of Clostridium difficile infection, (c) antimicrobial associated adverse events and (d) emergence of antimicrobial resistance at the patient level.