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It has been estimated that from 25 to 33 percent of hospitalized patients receive antibiotics and that in 22 to 65 percent of cases, these antibiotics are inappropriately or incorrectly prescribed. Fraser and associates developed a case-oriented educational approach to changing the prescribing behavior of clinicians and conducted a prospective randomized trial to evaluate the clinical, microbiologic and economic effectiveness of this intervention.

Elderly hospitalized patients receiving one or more of 10 designated parenteral antibiotics for three or more consecutive days over a three-month period were identified through pharmacy records and included in the study. A total of 252 patients were randomized to either an intervention group (141 patients) or a control group (111 patients). The intervention group received antibiotic-related suggestions from a team consisting of a pharmacist and an infectious disease specialist. These suggestions were placed in the medical progress note section of the patient's medical record. The groups were subsequently compared to determine the effectiveness of this intervention.

A total of 74 suggestions were made for 62 patients in the intervention group. Approximately 63 (85 percent) of the suggestions were implemented, with the majority (75 percent) involving changes in antibiotic choice, dosing regimen or route of administration. Evaluative disagreements between the investigators were uncommon and primarily involved assessing the status of patients to determine if they were stable enough to attempt changes in antibiotic treatment. There were no disagreements regarding antibiotic choice, route of administration, dosage or duration of treatment.

[ corrected] The ability to diminish antibiotic expenditures was in large part related to aggressive conversion of parenteral to oral formulations. Assessment of the economic benefit of implementing suggestions resulted in significantly fewer intravenous antibiotics being prescribed, reducing the number of hospital days required. Patients in the intervention group spent 1.6 fewer days taking parenteral antibiotics. The less intensive intravenous antibiotic treatment in the intervention group also reflected a trend toward lower defined daily dosages per patient treatment course. Eighty percent of patients in both groups showed clinical improvement. The intervention group required less retreatment with antibiotics (defined as the need for readministration of antibiotics within seven days) and a shorter duration of hospitalization.

Randomization to the intervention group was found to be a significant predictor of reduced charges for antibiotic therapy. The intervention blended three strategies successfully: it was initiated by opinion leaders in infectious disease, it offered patient-specific educational materials and it functioned as a reminder at the time of antibiotic assessment. Suggestions were offered in a noncoercive manner and were removed from the medical record within 24 hours. The authors believe that the success of the program was related to the focus on updating and expanding infectious disease knowledge, local resistance patterns, cost issues and antimicrobial options.

The authors conclude that 50 percent of patients in this study who were initially treated with parenteral antibiotics could have their regimens refined after three days of antibiotic therapy and that these modifications could be made safely and economically. The authors believe that their approach successfully guided physicians to the use of appropriate and cost-effective antibiotic alternatives without sacrificing the quality of care provided. By not interfering with the physician's choice of initial antibiotic therapy, diversity of utilization is maintained and the likelihood of developing antimicrobial resistance is lessened. This intervention also served as an acceptable quality assurance measure for the Joint Commission on Accreditation of Healthcare Organizations.

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