Many infectious disease societies have published clinical guidelines to control the use of antibiotics in hospital systems (19). Antibiotic control programs are implemented in an effort to optimize antibiotic use while minimizing antibiotic costs (32). The success of these programs depends on cooperation of multidisciplinary teams, including hospital administrators, clinicians, infectious diseases specialists, infection control teams, microbiologists, and hospital pharmacists (18). All team members must promote basic hospital infection control practices such as hand washing. Pharmacists and infection control teams are involved in monitoring of drug use, surveillance and reporting of antimicrobial resistance patterns, and detection of patients colonized with potentially resistant and communicable bacteria. Antibiotic control programs include antibiotic order forms developed by a team of infectious disease "experts," which reflect preferred dosing intervals. Programs may limit the duration of antibiotic therapy (automatic stop dates), or institute restrictions on antibiotic use for specific indications. Many antibiotic restriction programs require clinical justification for the specific antibiotic order prior to dispensing by the pharmacy. In a 1996 survey, 81% of university-affiliated teaching institutions used antibiotic restriction policies and 56% used official recommendations to guide antibiotic use. More than three quarters of these institutions contacted the provider for noncompliance with restriction policies, and almost half refused to dispense the drug if the prescriber refused to alter the order to meet restrictions (33).
Restriction of use of specific antibiotics and antibiotic classes has been effective in altering patterns of resistance in individual institutions. For example, in a 500-bed university-affiliated community hospital, 30-40% of nosicomial Klebsiella infections were cephalosporin resistant in 1995 (34). An antibiotic control policy was developed that, in general, excluded the use of cephalosporins, without prior approval of an infectious disease expert. In one year, an 81% reduction in hospital-wide cephalosporin use was documented, paired with a 140% increase in imipenem use. Ceftazidime-resistant Klebsiella was reduced by 36% in nosicomial infections, but this was accompanied by an increase in imipenem-resistant Pseudomonas aeruginosa. Overall, there was a reduction in multiply resistant pathogens, but the continued impact beyond this 1-yr intervention on antibiotic resistance is unknown.
With the increase in methacillin-resistant Staphylococcus aureus (nearly 40% of all S. aureus isolates in large hospitals) and our current limited treatment options limited to vancomycin, restriction policies are present in most hospital systems (35). In a large community hospital system, pharmacists placed a point-of-care reminder detailing the Centers for Disease Control guidelines for prudent use of vancomycin in all patient charts over a 1-yr period (36). During this time, appropriate use of vancomycin increased from 59% to 80%, and the use of vancomycin decreased by 75%.
In a broader health care system, the Finnish Study Group for Antimicrobial Resistance was established to address the national problem of erythromycin resistance among Group A streptococci (5). This national initiative restricted the use of ery-thromycin and other macrolide antibiotics in the treatment of respiratory and skin infections in outpatients, and was supported by a publicity campaign by local experts and opinion leaders to Finnish physicians. This initiative led to a decline in use of macrolide antibiotics from 2.4 defined daily doses per 1000 inhabitants in 1991 to 1.38 in 1992. In return, a decrease in the frequency of erythromycin resistance was noted from 16.5% in 1992 to 8.6% in 1996. It is important to note, however, that overall antibiotic use did not change as a result of this national initiative, and resistance patterns with other antibiotics were not studied.
Antibiotic control policies are usually institutional interventions, creating barriers to inappropriate practices and limiting prescriber autonomy. Administrative interventions may also come from governmental agencies that enforce specific practices by laws, regulations, or recommendations. These policies often require added personnel and must be maintained indefinitely to continue to achieve desired results. Success of antibiotic control policies depends on the definition of success. Antibiotic order forms are effective in controlling antibiotic use and reducing antibiotic costs. Antibiotic restriction policies are effective in altering specific resistance patterns. When held to a more important definition of success, such impact on overall resistance patterns and overall patient outcomes, antibiotic control policies have not been appropriately evaluated. Finally, the "hassle factor" of administrative interventions may create dissatisfaction among practicing physicians.
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