Skip to main content
    • Aa
    • Aa

Impact of Different Methods of Feedback to Clinicians After Postprescription Antimicrobial Review Based on the Centers for Disease Control and Prevention's 12 Steps to Prevent Antimicrobial Resistance Among Hospitalized Adults

  • Sara E. Cosgrove (a1), Alpa Patel (a2), Xiaoyan Song (a1), Robert E. Miller (a3), Kathleen Speck (a4), Amy Banowetz (a4), Rachel Hadler (a4), Ronda L. Sinkowitz-Cochran (a5), Denise M. Cardo (a5) and Arjun Srinivasan (a5)...

To evaluate (1) the framework of the 12 Steps to Prevent Antimicrobial Resistance Among Hospitalized Adults that is part of the Centers for Disease Control and Prevention (CDC) Campaign to Prevent Antimicrobial Resistance in Healthcare Settings, with regard to steps addressing antimicrobial use; and (2) methods of feedback to clinicians regarding antimicrobial use after postprescription review.


Prospective intervention to identify and modify inappropriate antimicrobial therapy.


A 1,000-bed, tertiary care teaching hospital.


Inpatients in selected medicine and surgery units receiving broad-spectrum antimicrobials for 48-72 hours.


We created a computer-based clinical-event detection system that automatically identified inpatients taking broad-spectrum and “reserve” antimicrobials for 48-72 hours. Although prior approval was required for initial administration of broad-spectrum and reserve antimicrobials, once approval was obtained, therapy with the antimicrobials could be continued indefinitely at the discretion of the treating clinician. Therapy that was ongoing at 48-72 hours was reviewed by an infectious diseases pharmacist or physician, and when indicated feedback was provided to clinicians to modify or discontinue therapy. Feedback was provided via a direct telephone call, a note on the front of the medical record, or text message sent to the clinician's pager. The acceptance rate of feedback was recorded and recommendations were categorized according to the 12 steps recommended by the CDC.


Interventions were recommended for 334 (30%) of 1,104 courses of antimicrobial therapy reviewed. A total of 87% of interventions fit into one of the CDC's 12 steps of prevention: 39% into step 3 (“target the pathogen”), 1% into step 4 (“access experts”), 3% into steps 7 and 8 (“treat infection, not colonization or contamination”), 18% into step 9 (“say ‘no’ to vancomycin”), and 26% into step 10 (“stop treatment when no infection”). The rate of compliance with recommendations to improve antimicrobial use was 72%. No differences in compliance were seen with the different methods of feedback.


Nearly one-third of antimicrobial courses did not follow the CDC's recommended 12 steps for prevention of antimicrobial resistance. Clinicians demonstrated high compliance with following suggestions made after postprescription review, suggesting that it is a useful approach to decreasing and improving antimicrobial use among inpatients.

Corresponding author
Osler 425, Johns Hopkins Hospital, 600 N. Wolfe St., Baltimore, MD 21287 (
Linked references
Hide All

This list contains references from the content that can be linked to their source. For a full set of references and notes please see the PDF or HTML where available.

1. DM Shales , DN Gerding ,, JF John , et al.. Society for Healthcare Epidemiology of America and Infectious Diseases Society of America Joint Committee on the Prevention Of Antimicrobial Resistance: guidelines for the prevention of antimicrobial resistance in hospitals. Infect Control Hosp Epidemiol 1997;18:275291.

2. DA Goldman , RA Weinstein , RP Wenzel , et al.. Strategies to prevent and control the emergence and spread of antimicrobial resistant microorganisms in hospitals. JAMA 1996;275:234240.

3. B Schwartz , DM Bell , JM Hughes . Preventing the emergence of antimicrobial resistance. JAMA 1997;278:944945.

7. AC White , RL Atmar , J Wilson , TR Cate , CE Stager , SB Greenberg . Effects of requiring prior authorization for selected antimicrobials: expenditures, susceptibilities and clinical outcomes. Clin Infect Dis 1997;25:230239.

8. RW Coleman , LC Rodondi , S Kaubisch , NB Granzella , PD O'Hanley . Cost-effectiveness of prospective and continuous parenteral antibiotic control: experience at the Palo Alto Veterans Affairs Medical Center. Am J Med 1991;90:439444.

9. JE McGowan , M Finland . Usage of antibiotics in a general hospital: effect of requiring justification. J Infect Dis 1974;130:165168.

10. RA Recco , JL Gladstone , SA Friedman , EH Gerken . Antibiotic control in a municipal hospital. JAMA 1979;241:2283.

11. A Paskovaty , JM Pflomm , N Myke , SK Seo . A multidisciplinary approach to antimicrobial stewardship: evolution into the 21st century. Int J Antimicrob Agents 2005;25:110.

13. R Gross , AS Morgan , DE Kinky , M Weiner , GA Gibson , NO Fishman . Impact of a hospital based antimicrobial management program on clinical and economic outcomes. Clin Infect Dis 2001;33:289-95.

14. JG Gums , RW Yancey , CA Hamilton , PS Kubilis . A randomized, prospective study measuring outcomes after antibiotic therapy intervention by a multidisciplinary consult team. Pharmacotherapy 1999;19:13691377.

15.Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med 2005;171:388416.

16. A Srinivasan , X Song , A Richards , R Sinkowitz-Cochran , D Cardo , C Rand . A survey of knowledge, attitudes, and beliefs of housestaff physicians from various specialties concerning antimicrobial use and resistance. Arch Intern Med 2004;164:14511456.

17. TB Giblin , RL Sinkowitz-Cochran , PL Harris , et al.; the CDC Campaign to Prevent Antimicrobial Resistance Team. Clinician perceptions of the problem of antimicrobial resistance in healthcare settings. Arch Intern Med 2004;164:16621668.

18. KJ Brinsley , A Srinivasan , RL Sinkowitz-Cochran , R Lawton , R Mclntyre , D Cardo . Implementation of the Campaign to prevent antimicrobial resistance in healthcare settings: 12 steps to prevent antimicrobial resistance among hospitalized adults—experiences from three institutions. Am J Infect Control 2005;33:5354.

Recommend this journal

Email your librarian or administrator to recommend adding this journal to your organisation's collection.

Infection Control & Hospital Epidemiology
  • ISSN: 0899-823X
  • EISSN: 1559-6834
  • URL: /core/journals/infection-control-and-hospital-epidemiology
Please enter your name
Please enter a valid email address
Who would you like to send this to? *


Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 3 *
Loading metrics...

Abstract views

Total abstract views: 132 *
Loading metrics...

* Views captured on Cambridge Core between September 2016 - 26th July 2017. This data will be updated every 24 hours.