Date of Award


Degree Type


Degree Name

Honors Thesis



First Advisor

Chad Knoderer


Background: Inappropriate use of antimicrobials in the healthcare setting is associated with consequences including antimicrobial resistance, Clostridium difficile infection (CDI), adverse drug reactions, and increased healthcare costs. To combat this, hospitals are creating antimicrobial stewardship programs (ASPs) which seek to optimize antimicrobial utilization. To date, no studies have been done to assess adherence to an ASP in a rehabilitation hospital setting. The objective of this study is to evaluate prescriber compliance to treatment pathways for common infections before and after ASP implementation.

Methods: This was a retrospective cohort study of patients admitted to the Rehabilitation Hospital of Indiana (RHI) who received an antibiotic between October 1, 2015-December 31, 2015 (pre-ASP group) and January 1, 2016-September 30, 2016 (post-ASP group) for one of the following indications: pneumonia, urinary tract infection, CDI, bone and joint infection, skin or skin structure infection, febrile neutropenia, or central/peripherally inserted central catheter line bloodstream infection. Data extracted from the hospital’s electronic medical record system included patient demographic and clinical information, laboratory data, culture and susceptibility results, and antibiotic information. The primary outcome of this study was prescriber compliance to treatment pathways defined as correct drug based on the documented indication before and after the implementation of the antimicrobial stewardship program on January 1, 2016. Descriptive statistics were performed to analyze baseline characteristics and culture data, as well as antimicrobial class, indication, and overall compliance to the guideline-based treatment pathways.

Results: Data was extracted from the hospital’s electronic medical record system for 381 patients (n=381) who received an antibiotic at RHI. There were 121 and 260 patients included in the pre- and post-ASP study groups, respectively. Urinary tract infections were the most common infection for which antibiotics were prescribed (n=293; 76.9%). The three most common antibiotics prescribed were ciprofloxacin (n=101; 26.5%), sulfamethoxazole/trimethoprim (n=81; 21.3%), and nitrofurantoin (n=49; 12.9%). Compliance was found to be 81% in the pre-ASP group and 78.5% in the post-ASP group (p=0.571). Overall compliance was found to be the highest (100% in both pre- and postASP groups) for osteomyelitis infections and CDI. Urinary tract infections had the next highest rate of compliance in both the pre- and post-ASP groups (86.5% and 81.7% respectively).

Conclusions: No difference in rates of prescriber compliance to guideline-based treatment pathways was found in the pre- and post-ASP groups. Urinary tract infections were found to be the most common indication requiring antimicrobial usage at RHI and had the third highest rate of compliance out of the infections included in this study. Our study highlights a need for further investigation regarding the impact of the ASP on appropriate antimicrobial dose, duration of therapy, administration, and de-escalation based on culture data. Additionally, our study identified a need for formal prescriber education focusing on how to utilize the treatment pathways, especially for those infections with the lowest compliance rates.