Impact of a direct stewardship intervention on prescribing practices for the management of uncomplicated gram-negative bloodstream infections

<h2>Abstract</h2><h3>Background</h3> Gram-negative bloodstream infections (GN BSIs) are associated with high rates of mortality and increased health care costs. Literature suggests that shorter courses (7 days) with the option to transition to highly bioavailable oral antibiotics are safe and efficacious. This project evaluated the impact of a direct stewardship intervention on prescribing practices for uncomplicated GN BSIs. <h3>Methodology</h3> This single-center, pre- and postintervention study was conducted at a large academic medical center. The intervention consisted of an uncomplicated GN BSI guideline followed by provider education and targeted prospective audit and feedback. Adult patients with uncomplicated GN BSIs from October 2021 to September 2022 (preintervention) and November 2022 to June 2023 (postintervention) were included, with October 2022 serving as a washout period. The primary outcome was calendar days of effective antibiotic therapy. <h3>Results</h3> A total of 142 uncomplicated GN BSIs (92 preintervention; 50 postintervention) were evaluated. Patients were predominantly African American (63%) with bloodstream infections primarily caused by <i>Escherichia coli</i> (42%) from a urinary source (66%). The median total duration of antibiotic therapy was 10 days (interquartile range [IQR] 8-11.5 days) in the preintervention group and 9 days (IQR 8-13 days) in the postintervention group (<i>P</i> = 0.514). Oral transition occurred in 41% versus 50% of patients in the pre- and postintervention groups, respectively (<i>P</i> = 0.319). In the postintervention group, 30-day mortality was significantly lower (9% vs. 0%, <i>P</i> = 0.05). There were no statistically significant differences in 30-day readmission or recurrence. <h3>Conclusions</h3> Implementation of guidelines with a direct stewardship intervention was associated with a numerically lower duration of therapy that was not statistically significant for GN BSIs, despite a nearly 10% increase in IV to oral transitions. No difference was seen in readmissions or recurrence between groups. This evaluation highlights the importance of antimicrobial stewardship interventions targeting the management of GN BSI and reveals an opportunity for a more focused intervention related to oral transition.