Skip to main content Accessibility help
Hostname: page-component-5d6d958fb5-gz6rp Total loading time: 0.284 Render date: 2022-11-28T01:32:46.555Z Has data issue: true Feature Flags: { "shouldUseShareProductTool": true, "shouldUseHypothesis": true, "isUnsiloEnabled": true, "useRatesEcommerce": false, "displayNetworkTab": true, "displayNetworkMapGraph": false, "useSa": true } hasContentIssue true

Economic Impact of Redundant Antimicrobial Therapy in US Hospitals

Published online by Cambridge University Press:  10 May 2016

Leslie Schultz
Premier Safety Institute, Premier, Charlotte, North Carolina
Timothy J. Lowe*
Premier Healthcare Alliance, Charlotte, North Carolina
Arjun Srinivasan
Centers for Disease Control and Prevention, Atlanta, Georgia
Dwight Neilson
Premier Healthcare Alliance, Charlotte, North Carolina
Gina Pugliese
Premier Safety Institute, Premier, Charlotte, North Carolina
Premier, 13034 Ballantyne Corporate Place, Charlotte, NC 28277 (



Overutilization of antimicrobial therapy places patients at risk for harm and contributes to antimicrobial resistance and escalating healthcare costs. Focusing on redundant or duplicate antimicrobial therapy is 1 recommended strategy to reduce overutilization and its attendant effects on patient safety and hospital costs


This study explored the incidence and economic impact of potentially redundant antimicrobial therapy.


We conducted a retrospective analysis of inpatient administrative data drawn from 505 nonfederal US hospitals. All hospitalized patients discharged between January 1, 2008, and December 31, 2011, were eligible for study inclusion. Potentially redundant antimicrobial therapy was identified from pharmacy records and was defined as patients receiving treatment with overlapping antibiotic spectra for 2 or more consecutive days.


We found evidence of potentially inappropriate, redundant antimicrobial coverage for 23 different antimicrobial combinations in 394 of the 505 (78%) hospitals, representing a total of 32,507 cases. High-frequency redundancies were observed in 3 antianaerobic regimens, accounting for 22,701 (70%) of the cases. Of these, metronidazole and piperacillin-tazobactam accounted for 53% (n = 17,326) of all potentially redundant cases. Days of redundant therapy totaled 148,589, representing greater than $12 million in potentially avoidable healthcare costs.


Our study suggests that there may be pervasive use of redundant antimicrobial therapy within US hospitals. Appropriate use of antimicrobials may reduce the risk of harm to patients and lower healthcare costs.

Original Article
© 2014 by The Society for Healthcare Epidemiology of America. All rights reserved.

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)


1. Society for Healthcare Epidemiology of America, Infectious Diseases Society of America, Pediatric Infectious Diseases Society. Policy statement on antimicrobial stewardship by the Society for Healthcare Epidemiology of America (SHEA), the Infectious Diseases Society of America (IDSA), and the Pediatric Infectious Diseases Society (PIDS). Infect Control Hosp Epidemiol 2012;33(4):322327.CrossRefGoogle Scholar
2. Flanders, SA, Saint, S. Why does antimicrobial overuse in hospitalized patients persist? JAMA Intern Med 2014;174(5)661662.CrossRefGoogle ScholarPubMed
3. Fridkin, S, Baggs, J, Fagan, R, et al. Vital Signs: Improving Antibiotic Use among Hospitalized Patients. Atlanta, GA: Centers for Disease Control and Prevention, 2014.Google ScholarPubMed
4. Centers for Disease Control and Prevention (CDC). Get Smart for Healthcare. Atlanta, GA: CDC, 2013. Accessed January 13, 2014.Google Scholar
5. Dellit, TH, Owens, RC, McGowan, JE, et al. Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clin Infect Dis 2007;44(2):159177.CrossRefGoogle Scholar
6. Hecker, MT, Aron, DC, Patel, NP, Lehmann, MK, Donskey, CJ. Unnecessary use of antimicrobials in hospitalized patients: current patterns of misuse with an emphasis on the antianaerobic spectrum of activity. Arch Intern Med 2003;163(8):972978.CrossRefGoogle ScholarPubMed
7. Spellberg, B, Bartlett, JG, Gilbert, DN. The future of antibiotics and resistance. N Engl J Med 2013;368(4):299302.CrossRefGoogle ScholarPubMed
8. Hersh, AL, Shapiro, DJ, Pavia, AT, Shah, SS. Antibiotic prescribing in ambulatory pediatrics in the United States. Pediatrics 2011;128(6):10531061.CrossRefGoogle ScholarPubMed
9. Davey, P, Brown, E, Charani, E, et al. Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database Syst Rev 2013;4:CD003543.CrossRefGoogle Scholar
10. Huttner, B, Jones, M, Rubin, MA, et al. Double trouble: how big a problem is redundant anaerobic antibiotic coverage in Veterans Affairs medical centres? J Antimicrob Chemother 2012;67(6):15371539.CrossRefGoogle ScholarPubMed
11. Polk, RE, Hohmann, SF, Medvedev, S, Ibrahim, O. Benchmarking risk-adjusted adult antibacterial drug use in 70 US academic medical center hospitals. Clin Infect Dis 2011;53(11):11001110.CrossRefGoogle ScholarPubMed
12. Mazeh, H, Mizrahi, I, Dior, U, et al. Role of antibiotic therapy in mild acute calculus cholecystitis: a prospective randomized controlled trial. World J Surg 2012;36(8):17501759.CrossRefGoogle ScholarPubMed
13. Gomi, H, Solomkin, JS, Takada, T, et al. TG13 antimicrobial therapy for acute cholangitis and cholecystitis. J Hepatobiliary Pancreat Sci 2013;20(1):6070.CrossRefGoogle ScholarPubMed
14. Solomkin, JS, Mazuski, JE, Bradley, JS, et al. Diagnosis and management of complicated intra-abdominal infection in adults and children: guidelines by the Surgical Infection Society and the Infectious Diseases Society of America. Clin Infect Dis 2010;50(2):133164.CrossRefGoogle ScholarPubMed
15. Goldin, AB, Sawin, RS, Garrison, MM, Zerr, DM, Christakis, DA. Aminoglycoside-based triple-antibiotic therapy versus monotherapy for children with ruptured appendicitis. Pediatrics 2007;119(5):905911.CrossRefGoogle ScholarPubMed
16. St. Peter, SD, Tsao, K, Spilde, TL, et al. Single daily dosing ceftriaxone and metronidazole vs standard triple antibiotic regimen for perforated appendicitis in children: a prospective randomized trial. J Pediatr Surg 2008;43(6):981985.CrossRefGoogle ScholarPubMed
17. Dubberke, ER, Butler, AM, Yokoe, DS, et al. Multicenter study of surveillance for hospital-onset Clostridium difficile infection by the use of ICD-9-CM diagnosis codes. Infect Control Hosp Epidemiol 2010;31(3):262268.CrossRefGoogle Scholar
18. Dubberke, ER, Reske, KA, McDonald, LC, Fraser, VJ. ICD-9 codes and surveillance for Clostridium difficile–associated diseases. Emerg Infect Dis 2006;12(10):15761579.CrossRefGoogle Scholar
19. Schmiedeskamp, M, Harpe, SE, Polk, RE, Oinonen, MJ, Pakyz, AL. Use of International Classification of Diseases, Ninth Revision, Clinical Modification codes and medication use data to identify nosocomial Clostridium difficile infection. Infect Control Hosp Epidemiol 2009;30(11):10701076.CrossRefGoogle ScholarPubMed
20. Schweizer, ML, Eber, MR, Laxminarayan, R, et al. Validity of ICD-9-CM coding for identifying incident methicillin-resistant Staphylococcus aureus (MRSA) infections: is MRSA infection coded as a chronic disease? Infect Control Hosp Epidemiol 2011;32(2):148154.CrossRefGoogle ScholarPubMed
21. National Quality Forum (NQF). Measure Evaluation Criteria. Washington, DC: NQF, 2011. Accessed March 12, 2012.Google ScholarPubMed
22. Cohen, SH, Gerding, DN, Johnson, S, et al. Clinical practice guidelines for Clostridium difficile infection in adults: 2010 update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA). Infect Control Hosp Epidemiol. 2010;31(5):431455.CrossRefGoogle Scholar
23. Liu, C, Bayer, A, Cosgrove, SE, et al. Clinical practice guidelines by the Infectious Diseases Society of America for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children. Clin Infect Dis 2011;52(3):e18e55.CrossRefGoogle Scholar
24. Wenisch, JM, Schmid, D, Tucek, G, et al. A prospective cohort study on hospital mortality due to Clostridium difficile infection. Infection 2012;40(5):479484.CrossRefGoogle ScholarPubMed
25. Friedenberg, F, Fernandez, A, Kaul, V, Niami, P, Levine, GM. Intravenous metronidazole for the treatment of Clostridium difficile colitis. Dis Colon Rectum 2001;44(8):11761180.CrossRefGoogle ScholarPubMed
26. Fekety, R, McFarland, LV, Surawicz, CM, Greenberg, RN, Elmer, GW, Mulligan, ME. Recurrent Clostridium difficile diarrhea: characteristics of and risk factors for patients enrolled in a prospective, randomized, double-blinded trial. Clin Infect Dis 1997;24(3):324333.CrossRefGoogle Scholar
27. Surawicz, CM, Brandt, LJ, Binion, DG, et al. Guidelines for diagnosis, treatment, and prevention of Clostridium difficile infections. Am J Gastroenterol 2013;108(4):478498.CrossRefGoogle ScholarPubMed
28. American Hospital Association (AHA). Fast Facts on US Hospitals 2014. Chicago: AHA, 2014. Accessed May 19, 2014.Google Scholar
29. American Hospital Association (AHA). Hospital Statistics: 2012 Edition. Chicago: AHA, 2012.Google Scholar
30. Lin, RY, Nuruzzaman, F, Shah, SN. Incidence and impact of adverse effects to antibiotics in hospitalized adults with pneumonia. J Hosp Med 2009;4(2):E7E15.CrossRefGoogle ScholarPubMed
31. Deresinski, S. Vancomycin in combination with other antibiotics for the treatment of serious methicillin-resistant Staphylococcus aureus infections. Clin Infect Dis 2009;49(7):10721079.CrossRefGoogle ScholarPubMed
32. Ramsey, TD, Lau, TTY, Ensom, MHH. Serotonergic and adrenergic drug interactions associated with linezolid: a critical review and practical management approach. Ann Pharmacother 2013;47(4):543560.CrossRefGoogle ScholarPubMed
33. Lahue, BJ, Pyenson, BS, Iwasaki, K, Blumen, HE, Forray, S, Rothschild, JM. National burden of preventable adverse drug events associated with inpatient injectable medications: healthcare and medical professional liability costs. Am Health Drug Benefits 2012;5(7):413422.Google ScholarPubMed
34. MacDougall, C, Polk, RE. Antimicrobial stewardship programs in health care systems. Clin Microbiol Rev 2005;18(4):638656.CrossRefGoogle ScholarPubMed
35. Bartlett, JG. A call to arms: the imperative for antimicrobial stewardship. Clin Infect Dis 2011;53(suppl 1):S4S7.CrossRefGoogle Scholar
36. Srinivasan, A, Fishman, N. Introduction: antimicrobial stewardship 2012: science driving practice. Infect Control Hosp Epidemiol 2012;33(4):319321.CrossRefGoogle Scholar
37. Freitas, JA, Silva-Costa, T, Marques, B, Costa-Pereira, A. Implications of data quality problems within hospital administrative databases. In: XII Mediterranean Conference on Medical and Biological Engineering and Computing: MEDICON 2010; May 2730, 2010; Chalkidiki, Greece.Google Scholar
38. David, MZ, Medvedev, S, Hohmann, SF, Ewigman, B, Daum, RS. Increasing burden of methicillin-resistant Staphylococcus aureus hospitalizations at US academic medical centers, 2003–2008. Infect Control Hosp Epidemiol 2012;33(8):782789.CrossRefGoogle ScholarPubMed
39. Lagu, T, Krumholz, HM, Dharmarajan, K, et al. Spending more, doing more, or both? an alternative method for quantifying utilization during hospitalizations. J Hosp Med 2013;8(7):373379.CrossRefGoogle ScholarPubMed
40. National Conference of State Legislators (NCSL). Uncovering Hospital Charges. Washington, DC: NCSL, 2013. Accessed February 18, 2014.Google ScholarPubMed
Cited by

Save article to Kindle

To save this article to your Kindle, first ensure is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about saving to your Kindle.

Note you can select to save to either the or variations. ‘’ emails are free but can only be saved to your device when it is connected to wi-fi. ‘’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

Find out more about the Kindle Personal Document Service.

Economic Impact of Redundant Antimicrobial Therapy in US Hospitals
Available formats

Save article to Dropbox

To save this article to your Dropbox account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you used this feature, you will be asked to authorise Cambridge Core to connect with your Dropbox account. Find out more about saving content to Dropbox.

Economic Impact of Redundant Antimicrobial Therapy in US Hospitals
Available formats

Save article to Google Drive

To save this article to your Google Drive account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you used this feature, you will be asked to authorise Cambridge Core to connect with your Google Drive account. Find out more about saving content to Google Drive.

Economic Impact of Redundant Antimicrobial Therapy in US Hospitals
Available formats

Reply to: Submit a response

Please enter your response.

Your details

Please enter a valid email address.

Conflicting interests

Do you have any conflicting interests? *