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Evaluation of Antimicrobial Therapy Orders Circumventing an Antimicrobial Stewardship Program: Investigating the Strategy of “Stealth Dosing”

  • Lori Ann LaRosa (a1), Neil O. Fishman (a2) (a3), Ebbing Lautenbach (a2) (a3) (a4) (a5), Ross J. Koppel (a5) (a6), Knashawn H. Morales (a4) (a5) and Darren R. Linkin (a2) (a3) (a5)...



Prior-approval antimicrobial stewardship programs (ASPs) improve patient outcomes and decrease antimicrobial resistance. These benefits would be limited if physicians circumvented ASP efforts. We evaluated whether prescribers wait until after the prior-approval period to order restricted antimicrobial therapy that is in conflict with guidelines or unnecessary.


A cross-sectional study design and a retrospective cohort study design.


A tertiary care, academic medical center with a prior-approval ASP that was active between 8 AM and 10 PM.


We evaluated whether there was an increase in the proportion of orders for antimicrobial therapy that involve restricted (vs nonrestricted) antimicrobials during the first hour that the ASP is inactive (ie, the first hour that prior approval is not required), compared with the remainder of the day. We also evaluated whether restricted antimicrobial therapy ordered during this first hour is less likely to be continued when the ASP becomes active the next day, compared with that ordered during the preceding hour.


A greater proportion of the antimicrobial therapy orders placed between 10:00 PM and 10:59 PM were for restricted agents, compared with orders placed during other periods (57.0% vs 49.9%; P = .02). Surgical patients for whom antimicrobial therapy orders were placed between 10:00 PM and 10:59 PM were less likely to have that antimicrobial therapy continued, compared with patients whose therapy was ordered between 9:00 PM and 9:59 PM (60.0% vs 98.1%; P <.001). Nonsurgical patients whose therapy orders were placed between 10:00PM and 10:59 PM were also less likely to have the ordered antimicrobial therapy continued, compared with patients whose therapy was ordered between 9:00 PM and 9:59 PM (70.8% vs 84.2%; P = .01).


Physicians avoid having to obtain prior approval for therapy involving restricted antimicrobials by waiting until restrictions are no longer active to place orders. Compared with restricted antimicrobial therapy ordered when the ASP is active, these courses of therapy are less often continued by the ASP, suggesting that they are more likely to be in conflict with guidelines or unnecessary.


Corresponding author

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1. Lawton, RM, Fridkin, SK, Gaynes, RP, McGowan, JE Jr. 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;21:256259.
2. John, JF Jr, Fishman, NO. Programmatic role of the infectious diseases physician in controlling antimicrobial costs in the hospital. Clin Infect Dis 1997;24:471485.
3. Gross, R, Morgan, AS, Kinky, DE, Weiner, M, Gibson, GA, Fishman, NO. Impact of a hospital-based antimicrobial management program on clinical and economic outcomes. Clin Infect Dis 2001;33:289295.
4. White, AC Jr, Armar, RL, Wilson, J, Cate, TR, Stager, CE, Greenberg, SB. Effects of requiring prior authorization for selected antimicrobials: expenditures, susceptibilities, and clinical outcomes. Clin Infect Dis 1997;25:230239.
5. 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;5:180188.
6. Ruttimann, S, Keck, B, Hartmeier, C, Maetzel, A, Bucher, HC. Long-term antibiotic cost savings from a comprehensive intervention program in a medical department of a university-affiliated teaching hospital. Clin Infect Dis 2004;38:348356.
7. Dunagan, WC, Medoff, G. Formulary control of antimicrobial usage. What price freedom? Diagn Microbiol Infect Dis 1993;16:265274.
8. Koppel, R, Metlay, JP, Cohen, A, et al. Role of computerized physician order entry systems in facilitating medication errors. JAMA 2005;293:11971203.
9. Guidelines for antibiotic therapy at the Hospital of the University of Pennsylvania: restricted antibiotic manual. Available at: Accessed July 17, 2006.
10. Diggle, PJ, Liang, KY, Zeger, SL. Analysis of Longitudinal Data. New York: Oxford University Press; 1994.
11. Localio, AR, Berlin, JA, Ten Have, TR, Rimmel, SE. Adjustments for center in multicenter studies: an overview. Ann Intern Med 2001;135:112123.
12. Calfee, DP, Brooks, J, Zirk, NM, Giannetta, ET, Scheid, WM, Farr, BM. A pseudo-outbreak of nosocomial infections associated with the introduction of an antibiotic management programme. J Hosp Infect 2003;55:2632.
13. Green, MJ, Farber, NJ, Ubel, PA, et al. Lying to each other: when internal medicine residents use deception with their colleagues. Arch Intern Med 2000;160:23172323.
14. Sexton, JB, Thomas, EJ, Helmreich, RL. Error, stress, and teamwork in medicine and aviation: cross sectional surveys. BMJ 2000;320:745749.


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