Acute Care/Hospitalization

Despite prior-approval requirements of hospitals for certain antimicrobials, doctors still manage to "stealth dose"

Hospital programs in which experts in antimicrobial drugs must approve the use of restricted antimicrobial agents are becoming widespread. However, some physicians find these prior-approval Antimicrobial Stewardship Programs (ASPs) inconvenient, stressful, and time-consuming. Physicians can also avoid obtaining prior approval for initial doses of restricted antimicrobials by placing orders after ASP hours (if the ASP is inactive overnight) when approval is not required. This "stealth dosing" of restricted antimicrobials is more likely to be in conflict with prescribing guidelines or unnecessary, note researchers at the University of Pennsylvania Center for Research and Education on Therapeutics.

Darren R. Linkin, M.D., M.S.C.E., and colleagues examined whether there was an increase in orders for restricted antimicrobials compared with therapy using unrestricted antimicrobials at one medical center with a prior-approval ASP.

Requests for restricted antimicrobial therapy were made by paging an Infectious Diseases (ID) specialist (ID-trained pharmacist or ID fellow). Outside of active program hours (between 10 pm and 8 am), physicians may order restricted antimicrobials without prior approval. However, approval must be obtained the next day to continue therapy with the restricted agent.

A greater proportion of all antimicrobial therapy orders placed between 10:00 pm and 11:00 pm were for restricted agents, compared with orders placed during all other hours (57 vs. 49.9 percent). Surgical and non-surgical patients for whom antimicrobial therapy orders were placed between 10:00 and 10:59 pm were less likely to have that antimicrobial therapy continued than patients whose therapy was ordered between 9:00 and 9:59 pm (60.0 vs. 98.1 percent and 70.8 vs. 84.2 percent, respectively). This suggests that later orders were either in conflict with guidelines or unnecessary.

The study was supported by the Agency for Healthcare Research and Quality (HS10399 and HS11530). More details are in "Evaluation of antimicrobial therapy orders circumventing an antimicrobial stewardship program: Investigating the strategy of 'stealth dosing'," by Lori Ann LaRosa, Pharm.D., Neil O. Fishman, M.D., Ebbing Lautenbach, M.D., M.P.H., M.S.C.E., and others, in the May 2007 Infection Control and Hospital Epidemiology 28(5), pp. 551-556.

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