Major article Longitudinal evaluation of a World Wide Webebased antimicrobial stewardship program: Assessing factors associated with approval patterns and trends over time Vidya Venugopal ScM a , Christoph U. Lehmann MD b , Marie Diener-West PhD c , Allison L. Agwu MD, ScM d, * a Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD b Department of Pediatrics and Biomedical Informatics, Vanderbilt University, Nashville, TN c Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD d Department of Pediatric and Adult Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD Key Words: Outcomes Approvals Antibiotic requests Background: The Johns Hopkins Children’s Medical and Surgery Center developed a Web-based Anti- microbial Stewardship Program (ASP) in 2005. The present study aimed to assess longitudinal antimi- crobial request and approval patterns for this ASP. Methods: We analyzed a total of 16,229 antimicrobial requests for 3,542 patients between June 1, 2005, and June 30, 2009. Antimicrobial approval was the outcome of interest. We assessed gaming by studying trends in automatically approved requests. Nonparametric tests for trend were performed to detect changes in approval patterns. Multiple logistic regression was used to identify factors associated with approval. Results: The vast majority (91.3%) of antimicrobial requests were approved, withan increase of 6.1% over time (P < .01). Renewal requests were more likely than primary requests (adjusted odds ratio [aOR],1.72; 95% confidence interval [CI], 1.45-2.04) to be approved. Antiviral requests had higher odds of approval than antibiotic requests (aOR, 1.27; 95% CI, 1.04-1.56). Compared with requests by medical services, re- quests by surgical services had lower odds of approval (aOR, 0.70; 95% CI, 0.59-0.83), whereas pediatric intensive care requests had higher odds of approval (aOR, 1.18; 95% CI, 1.00-1.40). The number of auto- approved requests remained consistent. Conclusions: The Web-based ASP allows management of a large number of antimicrobial requests, without apparent gaming. Observed differences in approval patterns based on patient, requestor, and antimicrobial factors may inform the development of ASPs and evaluation of provider education and training. Copyright Ó 2014 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved. The benefits of antimicrobial therapy have been mitigated by the emergence of antimicrobial resistance, which has significantly reduced the effectiveness of antimicrobials, chemicals, and other agents that prevent and cure infections. 1 Compared with infections with antimicrobial-susceptible organisms, infections with resistant organisms result in increased morbidity and mortality, increased length of stay, and ultimately increased health care costs. 2,3 The control of antimicrobial resistance requires a multipronged approach. Ideally, each institution needs a robust surveillance sys- tem that tracks resistant organisms, an infection control program that minimizes the transmission of pathogens, and finally an anti- microbial stewardship program (ASP). Antimicrobial stewardship involves the appropriate selection, dosing, route, and duration of antimicrobial therapy. 4,5 The primary goal of stewardship is to optimize clinical outcomes while minimizing the detrimental effects from nonjudicious and unnecessary 6 use of antimicrobials, such as increased toxicity, selection of pathogenic organisms, and emer- gence of resistance. 4 The secondary goal is to reduce health care costs without compromising the quality of health care provided. 4 The Johns Hopkins Children’s Medical and Surgery Center (JHCMSC), a 182-bed tertiary care hospital, introduced its ASP in * Address correspondence to Allison L. Agwu, MD, ScM, 200 North Wolfe St, Rm 3145, Baltimore, MD 21287. E-mail address: ageorg10@jhmi.edu (A.L. Agwu). A.L.A. was supported by the Johns Hopkins Ross Clinician Scientist Award, and a grant from the National Institute of Allergy and Infectious Diseases (1K23AI084549). C.U.L. is employed by the American Academy of Pediatrics. Conflict of interest: None to report. Contents lists available at ScienceDirect American Journal of Infection Control journal homepage: www.ajicjournal.org American Journal of Infection Control 0196-6553/$36.00 - Copyright Ó 2014 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajic.2013.09.018 American Journal of Infection Control 42 (2014) 100-5