Failure of a pharmacist-initiated antimicrobial step-down protocol to impact physician prescribing behavior or patient outcomes: A quasi-experimental, cross-over study
Bibliographic record
Abstract
Background: Intravenous (IV) to oral (PO) conversion may expedite hospital discharge and decrease costs. Most IV-to-PO programs include antimicrobials with highly-bioavailable PO formulations, allowing sequential interchanges. Our aim was to evaluate clinical and economic outcomes of a pharmacist-initiated antimicrobial step-down protocol whereby intravenous (IV) antimicrobials were switched to different oral (PO) antimicrobials. Methods: A 12-month quasi-experimental, cross-over study was conducted on a 45-bed adult general medicine ward in two populations (A & B) receiving an IV antimicrobial for ≥ 48 hours in three phases: baseline (Phase 1); step-down protocol in Group A only (Phase 2); and step-down protocol in Group B, withdrawn from Group A (Phase 3). A step-down conversion form was used by pharmacists to screen patients for eligibility. If eligible, the form was placed in the medical record to be completed by the physician. Outcomes reported after step-down eligibility included percent receiving step-down conversion; length of stay; therapy duration; IV complications; clinical cure; and antimicrobial and hospitalization costs. Results: 2,635 patients were screened. Of 595 included patients, 33.6% (n=98) and 32% (n=97) were eligible for step-down in Groups A and B, respectively. During Phase 2, 42.1% of the eligible Group A and 28.6% of the eligible Group B patients were switched to step-down therapy (p=0.12). No significant difference existed between the groups for length of stay; duration of therapy; IV complications; clinical cure; and costs. Similar results were observed in Phase 3. Post hoc analyses showed those receiving step-down conversion had shorter stays (p=0.02) and decreased hospitalization costs (p=0.006). Conclusions: Approximately 60%-75% of eligible patients did not receive step-down conversion. The step-down protocol was labor-intensive and poorly accepted. Successful step-down programs must anticipate these challenges. Step-down was associated with shorter stays and decreased costs.
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.024 | 0.017 |
| Meta-epidemiology (narrow) | 0.001 | 0.001 |
| Meta-epidemiology (broad) | 0.002 | 0.001 |
| Bibliometrics | 0.001 | 0.001 |
| Science and technology studies | 0.002 | 0.003 |
| Scholarly communication | 0.001 | 0.002 |
| Open science | 0.002 | 0.001 |
| Research integrity | 0.002 | 0.002 |
| Insufficient payload (model declined to judge) | 0.003 | 0.001 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".