Building a long-term antibiotic stewardship program
The Centers for Disease Control and Prevention (CDC) announced the arrival of "Get Smart About Antibiotics Week" (observed November 14-20, 2011) by launching a new antibiotic tracking system that will allow hospitals to monitor antibiotic usage and compare themselves to other hospitals in the region or across the country. The electronic system is part of the CDC's National Healthcare Safety Network.
Although the awareness campaign only lasted a week, it spotlighted a growing issue in hospitals across the country that only seems to be getting worse.
"The threat of untreatable infections is real," Arjun Srinivasan, MD, head of CDC's Get Smart for Healthcare program, said in a press release. "Although previously unthinkable, the day when antibiotics don't work in all situations is upon us. We are already seeing germs that are stronger than any antibiotics we have to treat them, including some infections in health care settings."
In April 2011, the CDC used World Health Day to draw attention to the issue of antibiotic resistance, which is becoming a worldwide issue. Plasmodium falciparum, a dangerous malaria parasite, has developed resistance to nearly every drug in Southeast Asia. H1N1 has shown sporadic resistance to flu vaccines. And in the United States, Klebsiella pneumoniae has been reported in 36 states, while MRSA has become even more prevalent in the hospital and community setting. From a financial perspective, antibiotic resistance costs an estimated $20 billion per year in healthcare costs in the United States and more than 8 million additional days spent in the hospital.
The staggering statistics associated with antibiotic resistance demand that healthcare facilities implement and sustain an effective antibiotic stewardship program that involves pharmacy, infection control, and microbiology. Doing so can drastically reduce antibiotic usage, while also providing a cost benefit to the hospital's bottom line.
Looking at long-term numbers
A study presented at the Infectious Diseases Society of America's (IDSA) annual meeting in Boston in October 2011 showed that a judicious stewardship program can reduce antibiotic resistance, while maintaining levels of usage over an extended period of time.
The retrospective study, conducted at Wesley Medical Center in Wichita, KS, reviewed antibiotic data over a 17-year period: from 1993, when the stewardship program began, to 2009. Data showed antibiotic resistance was improved or maintained for susceptible organisms such as P. aeruginosa, E. coli, and, K. pneumoniae.
Prior to implementation of the stewardship program, antibiotic usage registered at 22%. After one year, usage dropped to 14%, remaining at 9%-16% for the rest of the period.
The long-term nature of the study gave additional credence to the efficacy of a multidisciplinary stewardship program, says Derick Gross, PharmD, clinical pharmacist in adult medicine at Wesley Medical Center and lead author of the study.
"It certainly showed that at the very least, you can maintain your susceptibility profiles for various bacteria or even improve your resistance rates by decreasing your antibiotics usage," Gross says.
"There isn't any one thing we did, or it isn't necessarily even just decreasing antibiotic usage, because we're not able to make those formal ties. It's really the multidisciplinary approach to stewardship that has enabled us to have a long-term decrease in overall antibiotic usage and help yield better susceptibility profiles across our hospital."
Setting up your team
One of the most important aspects of creating an antibiotic stewardship program is assembling a multidisciplinary team that includes pharmacy, infection control, physician leadership, and microbiology.
Enlisting the expertise of an infectious disease (ID) physician helps incorporate a physician leader who can train and educate doctors on the front lines in appropriate prescribing practices. At Wesley there is a dedicated ID physician involved with stewardship who helps with training and developing policies.
"It really started with the ID physician taking charge of the program and really being the liaison with the prescribers throughout the hospitals," Gross says. "As time went on, as pharmacists had been working in the system for months or years, there became a natural comfort level with prescribers throughout the hospital as well as the ID physicians. Through the experience, they realized they can give pharmacy a little more autonomy."
The stewardship program is typically led by the pharmacy team, which tracks antibiotic usage and consults with physicians for alternative methods or dosages. The best way to communicate with physicians is to present them with evidence-based guidelines and recommendations for prescribing antibiotics.
"We talk about things like, your cultures are growing something your antibiotic won't cover, or your cultures are growing something that is very sensitive and we can narrow your antibiotics," says Mandelin Cooper, PharmD, clinical pharmacist in infectious diseases at Wesley.
"We also talk a lot about therapy. You don't need to treat three or four weeks for an infection. You can treat three days or seven days sometimes," Cooper adds.
She says the best way to approach physicians is with recommendations that are evidence-based and supported with data.
"It makes them trust us," she says. "It helps with the relationship where we've got a little more involvement in the beginning rather than the end of therapy. We are not the antibiotic police; we try really hard not to be in that role. Our goal is really to collaborate with the physicians to get the best patient care because it doesn't matter how expensive or cheap it is, the wrong drug is the wrong drug for the patient."
Tracking a moving target
Antibiotic resistance is a constantly moving target, so a quality stewardship program builds in a high degree of flexibility to cover a broad spectrum of antibiotics and organisms.
"There are studies that show over a very short time period we can drastically decrease our use of this broad-spectrum agent," Gross says. "But when they decrease resistance to that agent, they also increase resistance to this other agent because people in the hospital end up using this other broad-spectrum agent. You really want to do across the board, rather than one agent over another."
Cooper says she looks at a daily report that lists every patient who is on IV or oral antibiotics for three days or more. This gives her a real-time glimpse at the appropriate use of antibiotics.
She also communicates with infection control on a daily basis about particular outbreaks or areas where infection control may need to retrain staff members. Infection preventionists usually reciprocate that communication by asking pharmacists for antibiotic recommendations.
The collaboration takes the responsibility off of one group or person, allowing multiple disciplines to share their expertise.
"We try hard to work together, and there is stewardship a little bit everywhere, but in return I try to help with infection prevention," Cooper says. "I try to make sure patients are on contact precautions, that people are washing their hands and doing the right thing."
Achieving cost savings
Initially, hospitals may see a fair amount of cost savings from a stewardship program. In the first year of Wesley's program, antibiotic usage dropped from 22% to 14%. "The problem is you can't drop it another 12%the next year because then you're not even giving patients antibiotics, and that's not appropriate either,"Cooper says. "But you can show that there is maintenance; that you can maintain that and it's cost avoidance."
Administrators may be initially hesitant to dedicate an ID physician or pharmacist to stewardship, but the Wesley study shows that facilities can achieve a cost balance by reducing rates of resistance.
Rates of resistance lead to additional patient days, and add to the amount of money spent on antibiotics, according to the study.
Even if your facility doesn't have dedicated staff from each discipline devoted to antibiotic stewardship, a multidisciplinary team that can spend some of its time on stewardship issues can have a big impact by targeting the low-hanging fruit.
"Different hospitals have different resources," Coopersays. "We are fortunate here that all I do is antibiotic stewardship, but that's not the case in other places, where you might be doing antibiotic stewardship, and you're the ICU pharmacist, and you have to do order entry sometimes. You don't always have the personnel, so you sort of have to start where you can and go from there."
Simple initial steps
For facilities in the beginning stages of antibiotic stewardship, here are a few recommendations from Gross and Cooper to hit the ground running:
- Prioritize your problems. If you don't have the manpower to focus on everything, conduct a risk assessment, identify the organisms that are giving you the most trouble, then zero in your efforts on those drugs.
- Switch antibiotics from IV to oral. Transitioning antibiotics from IV to oral whenever possible reduces the risk of further infections from an IV.
- Review dosages. Review prescriptions and ensure physicians are prescribing the right dosage, and lower those dosages whenever possible. Talk with physicians about the need to use fewer antibiotics to reduce resistance rates.
- Turn to national guidelines. When in doubt, organizations like the CDC and IDSA offer guidelines for starting a program and list evidence-based recommendations for stewardship.
There are a number of resources available for starting an antibiotic stewardship program and then maintaining resistance rates. Two of the most comprehensive guidelines come from the Infectious Diseases Society of America (IDSA): Extending the Cure and Combating Antimicrobial Resistance: Policy Recommendations to Save Lives.
Extending the Cure was published by IDSA in 2007 as a blueprint to combat the growing threat of antibiotic resistance in healthcare. In it, the authors describe the role of healthcare, as well as other sectors like the federal government, health insurance, and physicians. Specifically, the document lays out actions for infection control including surveillance and patient isolation, regional cooperation, and infection and resistance reporting.
Combating Antimicrobial Resistance: Policy Recommendations to Save Lives, meanwhile, was published in May 2011 by IDSA as a supplement in Clinical Infectious Diseases. This document offers current policy guidelines for antibiotic stewardship for hospitals to use when establishing and maintaining a program.
Both of these resources are available through IDSA's 10 x '20 initiative, which has the goal of producing 10 new viable antibiotics by 2020 (www.idsociety.org/10x20).
Additionally, the Centers for Disease Control and Prevention's "Get Smart About Antibiotics" campaign is a great place for a wide variety of resources, from planning materials to posters and even podcasts, that discuss resistance. Program leaders can find an evaluation manual for antibiotic usage along with a number of helpful surveillance tools.