Disease Management & Health Outcomes

, Volume 11, Issue 11, pp 723–736 | Cite as

Impact of Antimicrobial Control Programs on Patient Outcomes

Pharmacy Perspective
Review Article


Antimicrobial control programs are now commonplace in institutional settings, with pharmacists taking a central role in their inception and implementation. These programs often contain a variety of individual systems including formularies, restricted access, clinical pathways, antimicrobial management services, streamlining, intravenous to oral conversions and provider education. Economic concerns and the desire to limit antimicrobial resistance have driven a majority of these programs. Most antimicrobial controls have a potential to improve patient care through appropriate antimicrobial use and avoidance of adverse drug effects. However, there also exists a potential for impairing patient outcomes by dictating antimicrobial selection and use. The impact of these programs on patient clinical outcomes is not well documented. In studies where clinical outcomes were collected, most found no significant differences in resolution of infection, mortality, or the incidence of adverse drug reactions. However, no studies reported a significant negative impact on patient outcomes. Further research is needed to evaluate the clinical impact of antimicrobial control programs. It is imperative to combine clinical outcomes with the economic and resistance outcomes generated. Pharmacists must continue to be involved in antimicrobial control programs and should strive to include patient outcomes in all evaluations.



The authors received no sources of funding for this article. They have no conflicts of interest directly relevant to the content of this review.


  1. 1.
    McGarvey RN, Harper JJ. Pneumonia mortality reduction and quality improvement in a community hospital. QRB Qual Rev Bull 1993; 19(4): 124–30PubMedGoogle Scholar
  2. 2.
    Gross PA, Pujat D. Implementing practice guidelines for appropriate antimicrobial usage: a systematic review. Med Care 2001; 39(8 Suppl. 2): 1155–69Google Scholar
  3. 3.
    Crowe HM, Quintiliani R. Antibiotic formulary selection. Med Clin North Am 1995; 79(3): 463–76PubMedGoogle Scholar
  4. 4.
    Price J, Ekleberry A, Grover A, et al. Evaluation of clinical practice guidelines on outcome of infection in patients in the surgical intensive care unit. Crit Care Med 1999; 27(10): 2118–24PubMedCrossRefGoogle Scholar
  5. 5.
    Estrada CA, Unterborn JN, Price J, et al. Judging the effectiveness of clinical pathways for pneumonia: the role of risk adjustment. Eff Clin Pract 2000; 3(5): 221–8PubMedGoogle Scholar
  6. 6.
    Metersky ML. Community-acquired pneumonia: process of care studies. Curr Opin Infect Dis 2002; 15(2): 169–74PubMedCrossRefGoogle Scholar
  7. 7.
    Al-Eidan FA, McElnay JC, Scott MG, et al. Use of a treatment protocol in the management of community-acquired lower respiratory tract infection. J Antimicrob Chemother 2000; 45(3): 387–94PubMedCrossRefGoogle Scholar
  8. 8.
    Klapp DL, Ramphal R. Antibiotic restriction in hospitals associated with medical schools. Am J Hosp Pharm 1983; 40(11): 1957–60PubMedGoogle Scholar
  9. 9.
    Anonymous. Hospital antibiotic control measures in the UK. Working Party of the British Society for Antimicrobial Chemotherapy. J Antimicrob Chemother 1994; 34(1): 21–42Google Scholar
  10. 10.
    Lesar TS, Briceland LL. Survey of antibiotic control policies in university-affiliated teaching institutions. Ann Pharmacother 1996; 30(1): 31–4PubMedGoogle Scholar
  11. 11.
    Lawton RM, Fridkin SK, Gaynes RP, et al. Practices to improve antimicrobial use at 47 US hospitals: the status of the 1997 SHEA/IDSA position paper recommendations: Society for Healthcare Epidemiology of America/Infectious Diseases Society of America. Infect Control Hosp Epidemiol 2000; 21(4): 256–9PubMedCrossRefGoogle Scholar
  12. 12.
    Knox K, Lawson W, Dean B, et al. Multidisciplinary antimicrobial management and the role of the infectious diseases pharmacist: a UK perspective. J Hosp Infect 2003; 53(2): 85–90PubMedCrossRefGoogle Scholar
  13. 13.
    Jennings HR, Empey PE, Smith KM. Survey of ASHP-accredited pharmacy residency programs. Am J Health Syst Pharm 2000; 57(22): 2080–6PubMedGoogle Scholar
  14. 14.
    Urban C, Mariano N, Rahman N, et al. Detection of multiresistant ceftazidimesusceptible Klebsiella pneumoniae isolates lacking TEM-26 after class restriction of cephalosporins. Microb Drug Resist 2000; 6(4): 297–303PubMedCrossRefGoogle Scholar
  15. 15.
    Zaas AK, Song X, Tucker P, et al. Risk factors for development of vancomycin-resistant enterococcal bloodstream infection in patients with cancer who are colonized with vancomycin-resistant enterococci. Clin Infect Dis 2002; 35(10): 1139–46PubMedCrossRefGoogle Scholar
  16. 16.
    Monroe S, Polk R. Antimicrobial use and bacterial resistance. Curr Opin Microbiol 2000; 3(5): 496–501PubMedCrossRefGoogle Scholar
  17. 17.
    Cosgrove SE, Sakoulas G, Perencevich EN, et al. Comparison of mortality associated with methicillin-resistant and methicillin-susceptible Staphylococcus aureus bacteremia: a meta-analysis. Clin Infect Dis 2003; 36(1): 53–9PubMedCrossRefGoogle Scholar
  18. 18.
    Niederman MS. Impact of antibiotic resistance on clinical outcomes and the cost of care. Crit Care Med 2001; 29(4 Suppl.): N114–20PubMedCrossRefGoogle Scholar
  19. 19.
    Lesch CA, Itokazu GS, Danziger LH, et al. Multi-hospital analysis of antimicrobial usage and resistance trends. Diagn Microbiol Infect Dis 2001; 41(3): 149–54PubMedCrossRefGoogle Scholar
  20. 20.
    de Man P, Verhoeven BA, Verbrugh HA, et al. An antibiotic policy to prevent emergence of resistant bacilli. Lancet 2000; 355(9208): 973–8PubMedCrossRefGoogle Scholar
  21. 21.
    Recco RA, Gladstone JL, Friedman SA, et al. Antibiotic control in a municipal hospital. JAMA 1979; 241(21): 2283–6PubMedCrossRefGoogle Scholar
  22. 22.
    Landman D, Chockalingam M, Quale JM. Reduction in the incidence of methicillin-resistant Staphylococcus aureus and ceftazidime-resistant Klebsiella pneumoniae following changes in a hospital antibiotic formulary. Clin Infect Dis 1999; 28(5): 1062–6PubMedCrossRefGoogle Scholar
  23. 23.
    Gerding DN, Larson TA, Hughes RA, et al. Aminoglycoside resistance and aminoglycoside usage: ten years of experience in one hospital. Antimicrob Agents Chemother 1991; 35(7): 1284–90PubMedCrossRefGoogle Scholar
  24. 24.
    Moss WJ, Beers MC, Johnson E, et al. Pilot study of antibiotic cycling in a pediatric intensive care unit. Crit Care Med 2002; 30(8): 1877–82PubMedCrossRefGoogle Scholar
  25. 25.
    Phillips I. Prudent use of antibiotics: are our expectations justified? Clin Infect Dis 2001; 33 Suppl. 3: S130–2PubMedCrossRefGoogle Scholar
  26. 26.
    Schumock GT, Butler MG, Meek PD, et al. Evidence of the economic benefit of clinical pharmacy services: 1996–2000. Pharmacotherapy 2003; 23(1): 113–32PubMedCrossRefGoogle Scholar
  27. 27.
    Lelekis M, Gould IM. Sequential antibiotic therapy for cost containment in the hospital setting: why not? J Hosp Infect 2001; 48(4): 249–57PubMedCrossRefGoogle Scholar
  28. 28.
    Davey P, Nathwani D. Sequential antibiotic therapy: the right patient, the right time and the right outcome. J Infect 1998; 37 Suppl. 1: 37–44PubMedCrossRefGoogle Scholar
  29. 29.
    Glazer WM. Formulary decisions and health economics. J Clin Psychiatry 1998; 59 Suppl. 19: 23–9PubMedGoogle Scholar
  30. 30.
    Johnson JA, Friesen E. Reassessing the relevance of pharmacoeconomic analyses in formulary decisions. Pharmacoeconomics 1998; 13(5): 479–85PubMedCrossRefGoogle Scholar
  31. 31.
    Jolicoeur LM, Jones-Grizzle AJ, Boyer JG. Guidelines for performing a pharmacoeconomic analysis. Am J Hosp Pharm 1992; 49(7): 1741–7PubMedGoogle Scholar
  32. 32.
    Caballero-Granado FJ, Becerril B, Cuberos L, et al. Attributable mortality rate and duration of hospital stay associated with enterococcal bacteremia. Clin Infect Dis 2001; 32(4): 587–94PubMedCrossRefGoogle Scholar
  33. 33.
    Blot SI, Vandewoude KH, Hoste EA, et al. Outcome and attributable mortality in critically Ill patients with bacteremia involving methicillin-susceptible and methicillin-resistant Staphylococcus aureus. Arch Intern Med 2002; 162(19): 2229–35PubMedCrossRefGoogle Scholar
  34. 34.
    Girou E, Stephan F, Novara A, et al. Risk factors and outcome of nosocomial infections: results of a matched case-control study of ICU patients. Am J Respir Crit Care Med 1998; 157(4 Pt 1): 1151–8PubMedGoogle Scholar
  35. 35.
    Mortensen EM, Coley CM, Singer DE, et al. Causes of death for patients with community-acquired pneumonia: results from the Pneumonia Patient Outcomes Research Team cohort study. Arch Intern Med 2002; 162(9): 1059–64PubMedCrossRefGoogle Scholar
  36. 36.
    Eron LJ, Passos S. Early discharge of infected patients through appropriate antibiotic use. Arch Intern Med 2001; 161(1): 61–5PubMedCrossRefGoogle Scholar
  37. 37.
    Basskin L. Assessing the impact of length of stay in a pharmacoeconomic analysis. Formulary 1997; 32: 733–9Google Scholar
  38. 38.
    McCormick D, Fine MJ, Coley CM, et al. Variation in length of hospital stay in patients with community-acquired pneumonia: are shorter stays associated with worse medical outcomes? Am J Med 1999; 107(1): 5–12PubMedCrossRefGoogle Scholar
  39. 39.
    Bassetti M, Di Biagio A, Rebesco B, et al. The effect of formulary restriction in the use of antibiotics in an Italian hospital. Eur J Clin Pharmacol 2001; 57(6–7): 529–34PubMedCrossRefGoogle Scholar
  40. 40.
    Gerding DN. Antimicrobial cycling: lessons learned from the aminoglycoside experience. Infect Control Hosp Epidemiol 2000; 21(1 Suppl.): S12–7PubMedCrossRefGoogle Scholar
  41. 41.
    Kollef MH, Vlasnik J, Sharpless L, et al. Scheduled change of antibiotic classes: a strategy to decrease the incidence of ventilator-associated pneumonia. Am J Respir Crit Care Med 1997; 156(4 Pt 1): 1040–8PubMedGoogle Scholar
  42. 42.
    Gruson D, Hilbert G, Vargas F, et al. Rotation and restricted use of antibiotics in a medical intensive care unit: impact on the incidence of ventilator-associated pneumonia caused by antibiotic-resistant gram-negative bacteria. Am J Respir Crit Care Med 2000; 162(3 Pt 1): 837–43PubMedGoogle Scholar
  43. 43.
    Dominguez EA, Smith TL, Reed E, et al. A pilot study of antibiotic cycling in a hematology-oncology unit. Infect Control Hosp Epidemiol 2000; 21(1 Suppl.): S4–8PubMedCrossRefGoogle Scholar
  44. 44.
    Raymond DP, Pelletier SJ, Crabtree TD, et al. Impact of a rotating empiric antibiotic schedule on infectious mortality in an intensive care unit. Crit Care Med 2001; 29(6): 1101–8PubMedCrossRefGoogle Scholar
  45. 45.
    Woodward RS, Medoff G, Smith MD, et al. Antibiotic cost savings from formulary restrictions and physician monitoring in a medical-school-affiliated hospital. Am J Med 1987; 83(5): 817–23PubMedCrossRefGoogle Scholar
  46. 46.
    Schentag JJ. Antimicrobial management strategies for Gram-positive bacterial resistance in the intensive care unit. Crit Care Med 2001; 29(4 Suppl.): N100–7PubMedCrossRefGoogle Scholar
  47. 47.
    Himmelberg CJ, Pleasants RA, Weber DJ, et al. Use of antimicrobial drugs in adults before and after removal of a restriction policy. Am J Hosp Pharm 1991; 48(6): 1220–7PubMedGoogle Scholar
  48. 48.
    DeVito JM, John Jr JF. Effect of formulary restriction of cefotaxime usage. Arch Intern Med 1985; 145(6): 1053–6PubMedCrossRefGoogle Scholar
  49. 49.
    Thuong M, Shortgen F, Zazempa V, et al. Appropriate use of restricted antimicrobial agents in hospitals: the importance of empirical therapy and assisted re-evaluation. J Antimicrob Chemother 2000; 46(3): 501–8PubMedCrossRefGoogle Scholar
  50. 50.
    Vlahovic-Palcevski V, Morovic M, Palcevski G. Antibiotic utilization at the university hospital after introducing an antibiotic policy. Eur J Clin Pharmacol 2000; 56(1): 97–101PubMedCrossRefGoogle Scholar
  51. 51.
    Frank MO, Batteiger BE, Sorensen SJ, et al. Decrease in expenditures and selected nosocomial infections following implementation of an antimicrobial-prescribing improvement program. Clin Perform Qual Health Care 1997; 5(4): 180–8PubMedGoogle Scholar
  52. 52.
    White Jr AC, Atmar RL, Wilson J, et al. Effects of requiring prior authorization for selected antimicrobials: expenditures, susceptibilities, and clinical outcomes. Clin Infect Dis 1997; 25(2): 230–9PubMedCrossRefGoogle Scholar
  53. 53.
    Bamberger DM, Dahl SL. Impact of voluntary vs enforced compliance of third-generation cephalosporin use in a teaching hospital. Arch Intern Med 1992; 152(3): 554–7PubMedCrossRefGoogle Scholar
  54. 54.
    Gentry CA, Greenfield RA, Slater LN, et al. Outcomes of an antimicrobial control program in a teaching hospital. Am J Health Syst Pharm 2000; 57(3): 268–74PubMedGoogle Scholar
  55. 55.
    Prado MA, Lima MP, Gomes Ida R, et al. The implementation of a surgical antibiotic prophylaxis program: the pivotal contribution of the hospital pharmacy. Am J Infect Control 2002; 30(1): 49–56PubMedCrossRefGoogle Scholar
  56. 56.
    Berild D, Ringertz SH, Aabyholm G, et al. Impact of an antibiotic policy on antibiotic use in a paediatric department: individual based follow-up shows that antibiotics were chosen according to diagnoses and bacterial findings. Int J Antimicrob Agents 2002; 20(5): 333–8PubMedCrossRefGoogle Scholar
  57. 57.
    Pestotnik SL, Classen DC, Evans RS, et al. Implementing antibiotic practice guidelines through computer-assisted decision support: clinical and financial outcomes. Ann Intern Med 1996; 124(10): 884–90PubMedGoogle Scholar
  58. 58.
    Armstrong EP. Clinical and economic outcomes of an ambulatory urinary tract infection disease management program. Am J Manag Care 2001; 7(3): 269–80PubMedGoogle Scholar
  59. 59.
    Atlas SJ, Benzer TI, Borowsky LH, et al. Safely increasing the proportion of patients with community-acquired pneumonia treated as outpatients: an interventional trial. Arch Intern Med 1998; 158(12): 1350–6PubMedCrossRefGoogle Scholar
  60. 60.
    Evans RS, Pestotnik SL, Classen DC, et al. A computer-assisted management program for antibiotics and other antiinfective agents. N Engl J Med 1998; 338(4): 232–8PubMedCrossRefGoogle Scholar
  61. 61.
    Gleason PP, Kapoor WN, Stone RA, et al. Medical outcomes and antimicrobial costs with the use of the American Thoracic Society guidelines for outpatients with community-acquired pneumonia. JAMA 1997; 278(1): 32–9PubMedCrossRefGoogle Scholar
  62. 62.
    Ibrahim EH, Ward S, Sherman G, et al. Experience with a clinical guideline for the treatment of ventilator-associated pneumonia. Crit Care Med 2001; 29(6): 1109–15PubMedCrossRefGoogle Scholar
  63. 63.
    Marrie TJ, Lau CY, Wheeler SL, et al. A controlled trial of a critical pathway for treatment of community-acquired pneumonia. CAPITAL Study Investigators. Community-Acquired Pneumonia Intervention Trial Assessing Levofloxacin. JAMA 2000; 283(6): 749–55PubMedCrossRefGoogle Scholar
  64. 64.
    Fraser GL, Stogsdill P, Dickens Jr JD, et al. Antibiotic optimization: an evaluation of patient safety and economic outcomes. Arch Intern Med 1997; 157(15): 1689–94PubMedCrossRefGoogle Scholar
  65. 65.
    Lemmen SW, Becker G, Frank U, et al. Influence of an infectious disease consulting service on quality and costs of antibiotic prescriptions in a university hospital. Scand J Infect Dis 2001; 33(3): 219–21PubMedCrossRefGoogle Scholar
  66. 66.
    Gums JG, Yancey Jr RW, Hamilton CA, et al. A randomized, prospective study measuring outcomes after antibiotic therapy intervention by a multidisciplinary consult team. Pharmacotherapy 1999; 19(12): 1369–77PubMedCrossRefGoogle Scholar
  67. 67.
    Barenfanger J, Short MA, Groesch AA. Improved antimicrobial interventions have benefits. J Clin Microbiol 2001; 39(8): 2823–8PubMedCrossRefGoogle Scholar
  68. 68.
    Chan R, Hemeryck L, O’Regan M, et al. Oral versus intravenous antibiotics for community acquired lower respiratory tract infection in a general hospital: open, randomised controlled trial. BMJ 1995; 310(6991): 1360–2PubMedCrossRefGoogle Scholar
  69. 69.
    Ramirez JA, Srinath L, Ahkee S, et al. Early switch from intravenous to oral cephalosporins in the treatment of hospitalized patients with community-acquired pneumonia. Arch Intern Med 1995; 155(12): 1273–6PubMedCrossRefGoogle Scholar
  70. 70.
    Terg R, Cobas S, Fassio E, et al. Oral ciprofloxacin after a short course of intravenous ciprofloxacin in the treatment of spontaneous bacterial peritonitis: results of a multicenter, randomized study. J Hepatol 2000; 33(4): 564–9PubMedCrossRefGoogle Scholar
  71. 71.
    Van den Brande P, Vondra V, Vogel F, et al. Sequential therapy with cefuroxime followed by cefuroxime axetil in community-acquired pneumonia. Chest 1997; 112(2): 406–15PubMedCrossRefGoogle Scholar
  72. 72.
    Przybylski KG, Rybak MJ, Martin PR, et al. A pharmacist-initiated program of intravenous to oral antibiotic conversion. Pharmacotherapy 1997; 17(2): 271–6PubMedGoogle Scholar
  73. 73.
    Ehrenkranz NJ, Nerenberg DE, Shultz JM, et al. Intervention to discontinue parenteral antimicrobial therapy in patients hospitalized with pulmonary infections: effect on shortening patient stay. Infect Control Hosp Epidemiol 1992; 13(1): 21–32PubMedCrossRefGoogle Scholar
  74. 74.
    Ehrenkranz NJ, Nerenberg DE, Slater KC, et al. Intervention to discontinue parenteral antimicrobial therapy in hospitalized patients with urinary tract infection, skin and soft tissue infection, or no evident infection. Infect Control Hosp Epidemiol 1993; 14(9): 517–22PubMedCrossRefGoogle Scholar
  75. 75.
    Paladino JA, Sperry HE, Backes JM, et al. Clinical and economic evaluation of oral ciprofloxacin after an abbreviated course of intravenous antibiotics. Am J Med 1991; 91(5): 462–70PubMedCrossRefGoogle Scholar
  76. 76.
    Ahkee S, Smith S, Newman D, et al. Early switch from intravenous to oral antibiotics in hospitalized patients with infections: a 6-month prospective study. Pharmacotherapy 1997; 17(3): 569–75PubMedGoogle Scholar
  77. 77.
    Bailey TC, Ritchie DJ, McMullin ST, et al. A randomized, prospective evaluation of an interventional program to discontinue intravenous antibiotics at two tertiary care teaching institutions. Pharmacotherapy 1997; 17(2): 277–81PubMedGoogle Scholar
  78. 78.
    Hendrickson JR, North DS. Pharmacoeconomic benefit of antibiotic step-down therapy: converting patients from intravenous ceftriaxone to oral cefpodoxime proxetil. Ann Pharmacother 1995; 29(6): 561–5PubMedGoogle Scholar
  79. 79.
    Adu A, Simpson JM, Armour CL. Attitudes of pharmacists and physicians to antibiotic policies in hospitals. J Clin Pharm Ther 1999; 24(3): 181–9PubMedCrossRefGoogle Scholar
  80. 80.
    Murray MD, Kohler RB, McCarthy MC, et al. Attitudes of house physicians concerning various antibiotic-use control programs. Am J Hosp Pharm 1988; 45(3): 584–8PubMedGoogle Scholar
  81. 81.
    Smyth ET, Tillotson GS. Sequential antimicrobial therapy: comparison of the views of microbiologists and pharmacists. J Infect 1998; 37 Suppl. 1: 18–23PubMedCrossRefGoogle Scholar
  82. 82.
    Gross R, Morgan AS, Kinky DE, et al. Impact of a hospital-based antimicrobial management program on clinical and economic outcomes. Clin Infect Dis 2001; 33(3): 289–95PubMedCrossRefGoogle Scholar
  83. 83.
    Keely JL. Pharmacist scope of practice. Ann Intern Med 2002; 136(1): 79–85PubMedGoogle Scholar
  84. 84.
    Clinical Affairs Committee, Infectious Diseases Society of America. Hospital pharmacists and infectious diseases specialists. Clin Infect Dis 1997; 25: 802CrossRefGoogle Scholar

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Authors and Affiliations

  1. 1.Department of Pharmacy Practice, College of PharmacyOregon State UniversityPortlandUSA

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