Concurrent Antibiotic Review Programs--A Role for Infectious Diseases Specialists at Small Community Hospitals

SIR—The recent article by Petrak et al. [1] cites examples of antibiotic-utilization programs developed by infectious diseases (ID) specialists at either academic [2] or large urban medical centers [3]. We developed a concurrent antibiotic review program, similar to that reported by Fraser et al. [4], which resulted in significant cost savings and improved antibiotic utilization at our 120-bed community hospital. Our antibiotic support team (AST), which consisted of an ID specialist, a clinical pharmacist, and representatives from the infection-control department and microbiology laboratory at Glenwood Regional Medical Center (West Monroe, LA), performed concurrent chart reviews 3 days per week that targeted patients receiving multiple, prolonged, or high-cost antibiotic therapy. Data collected included diagnosis and indications for antibiotics currently received; age; weight; allergies; renal, hepatic, and gastrointestinal function; and microbiology reports. Recommendations were communicated to managing physicians via a confidential form that was temporarily placed in the chart but did not become part of the official medical record. Telephone calls were made if urgent communication was warranted. Physicians were not obligated to follow the AST's advice but were encouraged to request formal ID consultation if a conflict arose. The medical staff was initially apprehensive about this program, which was due somewhat to a perceived loss of prescriptive autonomy but more so to concerns of legal liability, especially if physicians chose to reject AST recommendations. However, as a subcommittee of the hospital's pharmacy and therapeutics committee, and because its work involved quality assurance and utilization review activities, the AST's records were kept separate from patient medical records and, therefore, were not subject to legal discovery. We also realized the limitations of clinical decisions based solely on chart-review data, and we were careful to make recommendations only in well-defined clinical scenarios. No suggestions were made if data were insufficient to allow a comfortable decision. In essence, we aimed at harvesting the “low-hanging fruit,” rather than delving into complicated management issues. After several months, the program had met with wide approval, and some physicians regularly requested review of their patients' charts. From January through December 2000, we made 488 recommendations. Three hundred and thirty-six (69%) were accepted and implemented; 126 (26%) were rejected; and 26 (5%) were cancelled because of patient discharge. Thirty-eight percent of recommendations were to discontinue 1 or more antibiotics, because of duplicate coverage, inappropriate use, or excessive duration; 33% were to change from intravenous to oral administration; 23% were to substitute or add an antibiotic to the regimen; and 6% were to change dosage. Antibiotic costs for the year 2000 averaged $14.77 per patient-day, compared with $18.21 per patient-day in 1999—a cost reduction of 19% and a total estimated savings of $177,000. Although we did not track clinical outcomes, no adverse events were reported in connection with this program. The AST required ∼8–12 h per week of the ID specialist's time. In addition to the financial and clinical benefits, concurrent antibiotic utilization programs can help smaller hospitals attract ID specialists to settings where lower patient volumes may not support traditional consultative practices. The Infectious Diseases Society of America, pharmacists, and hospital administrators should work together to promote further study and development of and financial support for these programs. I am grateful to Nancy M. Toedter, Theresa B. Reagan, John E. Zitzman, and Raymond Ford for their assistance in developing the antibiotics support team.