Hospital Pharmacy - June 2019 - 176

176
medical ICU services and the surgical ICU service.
Decentralized staff pharmacists are positioned throughout
the hospital and interact with the teams on an as-needed
basis. This study was granted exemption from institutional
review board review.

Current Antimicrobial Stewardship Initiatives
Antimicrobial prescription is regulated by an interdisciplinary antimicrobial stewardship team as well as an antimicrobial stewardship and restriction policy. Current policies in
place include antibiotic "time outs," prior authorization, and
prospective audit and feedback. Our formulary carbapenem
agents are meropenem and ertapenem, and these agents are
subject to prior authorization, whereby when ordered for a
patient, a single dose will be released by pharmacy pending
infectious diseases antimicrobial stewardship team approval
(ID approval) if the order does not meet a prespecified
approved indication. An infectious diseases-trained pharmacist meets daily Monday through Friday with the infectious
diseases attending physician and fellow to discuss patients
meeting stewardship criteria, and the pharmacist communicates the antimicrobial stewardship recommendations to the
teams. Other antimicrobial stewardship interventions are
made by decentralized pharmacists according to institutional
guidelines. No formalized institution-wide education has
been provided on behalf of the antimicrobial stewardship
team to date at our institution.

Survey Development, Distribution, and Domains
Assessed
The survey was created by a single investigator and independently validated by an infectious diseases pharmacist
and infectious diseases physician to ensure that questions
were suitable to answer the study objectives. The survey
was divided into 3 domains, including (1) provider demographics, (2) relative importance of various factors on the
decision to prescribe a carbapenem empirically, and (3)
baseline therapeutic knowledge. The survey was distributed to providers via email on October 30, 2017. A reminder
email was distributed 1 week following the initial email,
and the survey remained open for a total of 2 weeks. A full
copy of the survey is available in the Supplementary
Appendix.
Demographic data collected included current year of postgraduate training, practice area, percentage of time caring for
patients in an ICU, and self-reported average number of
patients treated weekly with a carbapenem. A Likert-type
scale of 1 to 5 (1 being least important; 5 being most important) was used in the assessment of factors influencing
empiric carbapenem prescription. These factors included
type of infection, severity of illness, suspected pathogens at
the site of infection, institutional resistance rates, history
of MDR organisms, immune status of the patient,

Hospital Pharmacy 54(3)
drug penetration at site of infection, drug allergies, attending
physician preference, cost of medication, and dosing frequency. A Likert-type scale of 1 to 5 (1 being least likely; 5
being most likely) was used in the assessment of factors
deterring empiric carbapenem use. These items included
alternative recommendation by pharmacists, need for ID
approval, spectrum of activity being too broad for given indication, risk for antibiotic resistance development, and presence of drug-drug interactions.
Multiple-choice questions were utilized to assess provider
knowledge of penicillin drug allergy and beta-lactam cross
reactivity rates, resistance rates according to the institutional
antibiogram, and evidence regarding treatment of infections
caused by extended-spectrum beta-lactamase (ESBL)-
producing Enterobacteriaceae.

Statistical Methods
Descriptive statistics were performed using Microsoft Excel
(Microsoft, Redmond, Washington). Likert-type scale
responses are reported using the weighted average score
ranging from 1 to 5 as previously described. Multiple-choice
answers were stratified both by level of training and by the
cohort as a whole and are reported as percentages. A discrimination index was calculated for multiple-choice questions to evaluate whether questions were suitable to
differentiate between respondents who were knowledgeable
on subject matter and those who were not.

Results
The survey was distributed to 416 active provider email
accounts and achieved an overall response rate of 22.8% (n =
95). The average time for respondents to complete the survey
was 3 minutes. Provider demographics are reported in Table
1. Overall, respondents were well distributed across all levels of training ranging from postgraduate year 1 through
attending physician with primary roles in internal medicine
and surgery. The majority (n = 71; 74.7%) of respondents
reported that 25% or less of their duty hours were in an ICU
setting.
The importance of various factors influencing empiric
carbapenem prescription is shown in Figure 1a. Providers
who responded to the survey identified that suspected pathogens at the site of infection, presence of drug allergies, history of MDR organisms, severity of illness, type of infection,
and local resistance rates were the factors bearing the largest
impact on the empiric use of carbapenems. The likelihood of
various factors deterring empiric carbapenem use based on
provider opinion is shown in Figure 1b. Providers viewed
alternative recommendations provided by pharmacists as the
most likely factor for using an alternative agent, followed by
the presence of drug-drug interactions, spectrum of activity
being too broad, concern for the risk of antibiotic resistance
development, and need for ID approval.

Hospital Pharmacy - June 2019

Table of Contents for the Digital Edition of Hospital Pharmacy - June 2019