Exploring unconventional antimicrobial stewardship models: options beyond traditional prospective audit and feedback

Background: Prospective audit and feedback (PAF) is a core antimicrobial stewardship strategy. Discontinuing PAF in favor of alternative interventions has not been previously evaluated. Methods: This descriptive study assessed changes in antimicrobial days of therapy per 1,000 patient days (DOTs/1,000 PD) following PAF removal at two urban hospitals. Preintervention PAF included daily review of broad-spectrum antibiotics and oral therapy transitions. Postintervention efforts emphasized system standardization, education, guideline optimization, and electronic medical record enhancements. Secondary outcomes included trends in antibiotics previously reviewed under PAF: antibiotics targeting methicillin-resistant Staphylococcus aureus (MRSA) or Pseudomonas aeruginosa , carbapenems, and oral antibiotics. Results: Hospital A demonstrated a change in the trend of DOTs/1,000 PD with a significant downward slope after PAF removal (−5.994; 95% CI −8.072 to −3.929; P < .001). Hospital B continued to down-trend postintervention. At hospital A, carbapenem use decreased significantly postintervention (slope change −0.117; 95% CI −0.198 to −0.036; P = .007), with no changes in anti-MRSA or anti-pseudomonal agents. Hospital B demonstrated increasing use of anti-MRSA (slope change + 0.394; 95% CI 0.198 to 0.589; P < .001), anti-pseudomonal (slope change + 0.378; 95% CI 0.075 to 0.681; P = .016), and carbapenem agents (slope change + 0.124; 95% CI 0.020 to 0.228; P = .021). No changes were observed in oral antibiotic use or C. difficile rates. Conclusion: Shifting stewardship resources away from PAF did not increase total antibiotic use trends. Broad-spectrum antibiotics increased modestly with unclear clinical significance (≤1.3 DOT/1,000 PD). Antimicrobial stewardship strategies, beyond PAF, should continue to be assessed to maximize effectiveness relative to effort.