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There are advantages and disadvantages to every metric used in antimicrobial stewardship programs (ASPs). The following chart identifies examples
but demonstrates there is no single best metric. As outlined in the Antimicrobial Stewardship Metrics and Evaluation presentation, it is most important
the metric you choose is measured reliably and consistently over time.
Length of The number of days that a Rx: Levofloxacin Provides a more accurate Cannot be used to compare use of
Therapy or patient receives systemic 500mg po od x 7d assessment of treatment different drugs
Treatment antimicrobial agents, irrespective LOT = 1 LOT x 7d = 7 duration vs. DOT
Period (LOT) of the number of different drugs. LOT
Therefore, LOT will be lower than The ratio of DOT/LOT may be
or equal to DOT because each Rx: Levofloxacin useful as a benchmarking proxy
antibiotic receives its own DOT. 750mg po od x 7d for the frequency of combination
LOT = 1 LOT x 7d = 7 antibiotic therapy vs.
LOT monotherapy. That is, ratio = 1,
identifies monotherapy; ratio > 1
Rx: Levofloxacin identifies combination therapy
750mg po od x 7d + (e.g. ciprofloxacin x 7 days:
Vancomycin 1g iv DOT = 1 DOT x 7d = 7 DOT
q12h x 7d LOT = 1 LOT x 7d = 7 LOT
LOT = 1 LOT x 7d = 7 DOT/LOT = 1; therefore
LOT monotherapy
Antibiogram based on unique Number of unique Easier to do than a per Less clinically important than
isolates* and susceptibility to isolates resistant and patient approach, since the number of episodes of AROs per
given antibiotics susceptible to a given information can be obtained patient
antibiotic: directly from a microbiology
database without a patient
P. aeruginosa in denominator
blood in critical care /
number of unique
blood cultures that
are resistant to
meropenem
C. difficile rate Number of patients with 2009: 75 cases C. C. difficile is a publicly
documented C. difficile infection difficile and 500 reported infection that all
divided by the number of patients admitted to institutions must comply
patients admitted to the ward, critical care in 2009 = with reporting. Therefore,
service or unit of interest over a 75/500 = 15% there is a lot of pressure on
specified time period institutions from senior
2011: 43 cases C. administration to reduce C.
difficile and 450 difficile rates.
patients admitted to
critical care over in This could also be used as a
2011 = 43/450 = 9.5% measureable Adverse Drug
Reaction (ADR) for antibiotic
Reduction in C. associated C. difficile -
difficile = (15 nosocomial (confirmed) or
9.5)/15 = 5.5/15 = antibiotic associated
37% reduction in C. diarrhea (unconfirmed)
difficile in 2011
compared to 2009
Antimicrobial Antimicrobial costs can be based 2009 Pharmacy drug Expenditures are easily Purchased and dispensed
Expenditures on: budget of $3,000,000 understood by and relevant costs are surrogate markers
acquisition (purchased), Antimicrobial to administrators for administered costs (what
dispensed or acquisition costs the patient actually receives)
administered over a defined $750,000 (25% of May be viewed favourably in
time period budget) offsetting costs of stewardship Difficulty in retrieving data
program and accuracy of actual
Costs can be expressed as Cost savings (percent consumption is greatest for
absolute dollar value, percent of reduction in Relatively easy to administered, followed by
total (purchased, dispensed or antimicrobial costs): determine acquisition dispensed and then
administered ) and/or per costs from purchasing purchased costs
patient-days a) overall antibiotic records
acquisition costs Acquisition costs can
The selected method of costing Costs adjusted by patient fluctuate with
antimicrobials can be tracked 2010 $750,000 days for comparisons contracts/suppliers, generics
monthly and annually hospital 2011 $675,000 between clinical services and with patient volume
wide, for specific clinical services Absolute decrease of may help to broadly (patient-days to normalize),
(e.g. ICU), classes of $75,000, equals 10% identify potential areas and therefore calculated cost
antimicrobials (e.g. reduction for stewardship reductions will not be
fluoroquinolones), individual initiatives reflective of stewardship
drugs (e.g. linezolid), or types of b) ICU antibiotic interventions
infections/indications (e.g. acquisition costs
ventilator associated pneumonia) Dispensed costs may not
2010 $100,000 account for returns to
(patient days = 2000, pharmacy
$50/patient-day)
2011 $75,000 Medication Administration
(patient days = 2000, Record reviews to obtain
$37.50/patient-day) administered drug data is
Absolute decrease of time consuming and not
$25,000, equivalent easily performed (bar coding
to a reduction of is not generally available)
$12.50/patient-day
It may be difficult to retrieve
antimicrobial costs for
specific clinical services or
wards depending on the
capability of the pharmacy
computer system
Grams of Grams of antimicrobial based on: Relatively easy to Provides a very rough
antimicrobials acquisition (purchased), determine grams of approximation of
dispensed or antimicrobial from antimicrobial use
administered over a defined time purchasing records
period
Grams adjusted by
-serves as an integral step to patient days for
determining DDD comparisons between
clinical services may help
to broadly identify
potential areas for
stewardship initiatives
As a general premise, it is recommended that surgical prophylaxis antibiotic use, applying any of the metrics detailed, be evaluated
separately from use of antimicrobials for treatment of infection, since inclusion of surgical prophylaxis will skew metric results. In addition
to the metrics provided, there is interest in standardizing any metric (e.g. DOT) to an assessment of severity of illness or infection type,
using definitions such as clinical severity line (CSL) determined from US Medicare Severity Diagnosis Related Groups (MS-DRGs) by the
Centers for Medicare and Medicaid Services (CMS) (http://www.ntis.gov/products/grouper.aspx)[Polk CID 2011]. This may be an
important benchmarking tool to enable fair comparisons between hospitals with different case mixes, or services within a hospital that
have different case mixes. However, this method of standardization is currently in the early stages and further investigation of the best
method(s) of standardization are necessary.
References:
Elligsen M, Walker SAN, Pinto R, Simor A, Mubareka S, Rachlis A, Allen V, Daneman N. Audit and Feedback to Reduce Broad-Spectrum
Antibiotic Use Among Intensive Care Unit Patients: A controlled Interrupted Time Series Analysis. Infection Control and Hospital
Epidemiology 2012; 33(4):354-361.
Haustein T, Gastmeier P, Holmes A, Lucet JC, Shannon RP, Pittet D, Harbarth S. Use of benchmarking and public reporting for infection
control in four high-income countries. Lancet Infectious Diseases, 2011. 11: 471-81.
Hindler JF, Barton M, Callihan DR, Erdman SM, Evangelista AT, Jenkins SG, Johnston J, Master R, McGowan JE Jr, Nimmo G, Stelling J.
Analysis and presentation of cumulative antimicrobial susceptibility test data; approved guideline third edition 2012;M39-A3:29(6):1-55.
Leung V, Gill S, Sauve J, Walker K, Stumpo C, Powis J. Growing a Positive Culture of Antimicrobial Stewardship in Community Hospital.
Canadian Journal of Hospital Pharmacy 2011; 64(5): 314-320.
Morris A, Brener S, Dresser L, Daneman N, Dellit TH, Avdic E, Bell CH. Use of a Structured Panel Process to Define Quality Metrics for
Antimicrobial Stewardship Programs. Infection Control and Hospital Epidemiology 2012; 33(5): 500-6.
Palmay L (Antimicrobial Stewardship Pharmacist Sunnybrook Health Sciences Centre). Benchmarking Antibiotic Use Measures. Pharmacy
Department Journal Club Handout. Sunnybrook Health Sciences Centre April 2012.
Polk RE, Hohmann SF, Medvedev S, Ibrahim O. Benchmarking Risk-Adjusted Adult Antibacterial Drug Use in 70 US Academic Medical
Center Hospitals. Clinical Infectious Diseases 2011;53(11):1100-10.
World Health Organization. Collaborating Centre for Drug Statistics Methodology. Anatomical Therapeutic Chemical (ATC) Index with
Defined Daily dose (DDD). Oslo, Norway: WHO, 2004. Available at: http://www.whocc.no/atcddd/.