Identification of High-Yield Targets for Antimicrobial Stewardship Program Efforts Within a Nonfreestanding Children\u27s Hospital

OBJECTIVES: Identify diagnoses with the highest likelihood of prompting antimicrobial stewardship program (ASP) recommendations and lowest probability of recommendation acceptance, investigate the impact of provider years in practice on recommendation receipt and acceptance, and simultaneously assess the influence of patient and provider-level variables associated with recommendations within a nonfreestanding children\u27s hospital. METHODS: Retrospective cohort study of antibiotic courses reviewed by the ASP staff from December 1, 2014 to November 30, 2016. Poisson regression was used to detect associations between diagnoses, provider years in practice, and the probability of recommendation receipt and acceptance. Multivariable logistic regression was used to simultaneously examine the influence of patient and provider-level characteristics on recommendation probability. RESULTS: A total of 938 inpatient encounters and 1170 antibiotic courses were included. Diagnoses were associated with provider receipt (P \u3c .001) and acceptance (P \u3c .001) of recommendations, with ear, nose, and throat and/or sinopulmonary diagnoses most likely to prompt recommendations (56%; 95% confidence interval [CI], 48-64) and recommendations for neonatal and/or infant diagnoses accepted least often (67%; 95% CI, 58-76). No associations were initially found between provider experience and recommendation receipt or acceptance, although multivariable analysis revealed a trend between increasing years in practice and recommendation likelihood (P = .001). Vancomycin usage (64%; 95% CI, 56-72) and ear, nose, and throat and/or sinopulmonary diagnoses (56%; 95% CI, 47-65) had the highest probability of a recommendation. Sensitivity analyses revealed that use of diagnosis-related clinical practice guidelines decreased recommendations and increased acceptance rates, especially for the surgery diagnosis category. CONCLUSIONS: High-yield targets for ASP activities at our nonfreestanding children\u27s hospital were identified. Clinical practice guidelines have the potential to decrease ASP workload, and their development should be particularly encouraged for ASPs with limited resources