Written by Gretchen Heber
In the 1990s, the U.S. Centers for Disease Control and Prevention realized that providers were writing too many antibiotic prescriptions and that action was needed to reduce overprescribing, according to Lauri Hicks, DO, director of the CDC’s Office of Antibiotic Stewardship.
Each year in the U.S., prescribers write more than 45 million antibiotic prescriptions. However, Hicks said, “An estimated 20 to 50 percent of all antibiotics used in humans in the United States may be inappropriate or unnecessary.” Hospitals are one source of these unnecessary prescriptions, which have contributed to antibiotic-resistant “superbugs” for which there may be no treatment. These superbugs include Clostridium difficile (C. difficile), carbapenem-resistant Enterobacteriaceae and Neisseria gonorrhoeae.
To stem the growth in antibiotic-resistant superbugs, hospitals are taking steps to halt antibiotic misuse and overuse through antibiotic stewardship programs, which detail protocols that guide the use of antibiotics in specific situations.
Such programs long have been recognized as effective in curbing antibiotic misuse and overuse. In addition, the Centers for Medicare & Medicaid Services has proposed requiring Medicare-participating hospitals to have antibiotic stewardship programs in place, and The Joint Commission, as of January of this year, assesses institutional antimicrobial stewardship programs as part of its accreditation survey.
As hospitals put antibiotic stewardship programs in place, there is a growing collection of best practices to help ensure a programs’ adoption and success. From getting the right people involved at the outset, to creating protocols that will help the program evolve over time, Texas hospitals weigh in on what’s working.
Identify Key Staff
According to many experts, getting leadership buy-in is a key to the success of these programs. “Ownership of the initiative at the top level is crucial before a single policy is committed to paper,” said Karen Kendrick, RN, MSN, director of clinical initiatives at the Texas Hospital Association.
Selecting influential managers to lead development and implementation also helps to establish a smooth rollout. Most hospitals designate a program leader, often a physician, as well as a pharmacy leader.
Midland Memorial Hospital’s pharmacy clinical manager and manager of the hospital’s antibiotic stewardship program, Michaela Daggett, Pharm.D, agrees with this strategy. “There has to be an infectious disease-trained physician, as well as a pharmacist, in charge of the program,” she said.
Getting buy-in, support and assistance from other medical personnel at each hospital is imperative, as well, said Daggett.
“Relationships with physicians and other key stakeholders in the hospital are crucial,” she said. “We’ve taken a collaborative approach with other departments, and they all give their thoughts on how things should work. We try really hard to maintain our relationships throughout the hospital, as this makes things run more smoothly.”
Other key groups include clinicians, nurses, infection preventionists, hospital epidemiologists, quality improvement staff, laboratory staff and information technology staff.
Larger hospitals may be able to hire full-time staff to implement and manage an antibiotic stewardship program, but smaller facilities might rely on part-time, off-site expertise, according to the CDC, which has developed resources to help hospitals build and maintain these programs.
Discover the right policies and protocols
A hospital’s stakeholders should play an active role in the development of an antibiotic stewardship program.
At the heart of the policy, leaders should establish recommended courses of treatment for particular infections where antibiotics might be a priority. Relying on a hospital’s drug utilization records is one of the most reliable sources for developing protocols, Seton Network infectious diseases clinical pharmacy specialist Dusten Rose, Pharm.D. said. These data reveal what drugs at what dosage and duration have worked effectively against specific organisms.
Without these records, a hospital might start with national guidelines followed by extensive conversations with local physicians and pharmacists.
Hospitals should consider cost and side effects as well. Examining whether potential side effects justify a drug’s use in a particular situation is important, as is determining whether a lower cost antibiotic is equal in other ways.
Geography plays an important role, said Rose. For example, the Infectious Disease Society of America has national guidelines that prescribe using a particular antibiotic for urinary tract infections. “We’ve found that if you look at that organism in our hospital, based on our experience, we can use a more-narrow drug.”
But a hospital in a very large city such as New York might encounter organisms that are more resistant to common protocols, said Rose. Those hospitals would have to adjust their protocols based on internal, localized data, he explained.
Design for evolution
Change happens. Processes improve. And innovation gets adopted at rapid rates. When a stewardship program already is in place, regular reviews and updates will occur. New drugs are continually coming on the market that may supersede existing protocols. Ensuring leaders are performing regular audits of the program is crucial.
One catalyst for reevaluating antibiotic protocols might be the acquisition of piece of technology. When Midland Memorial added sophisticated equipment that significantly sped up the bacterial identification process, they updated prescribed timelines for reevaluating antibiotic type and dose. Rose at Seton describes a similar situation in his hospitals, “When our microbiology lab gets fun new ‘toys,’ sophisticated instruments that can reduce wait times from two to five days to 90 minutes, we revise our protocols.”
Midland’s antibiotic stewardship task force team — pharmacists, doctors, nurses and other stakeholders — meets bi-monthly to assess the program’s effectiveness. The group examines rates of clostridium difficile infections, a potential indicator of antibiotic misuse. The task force also assesses drugs new to the market, deciding whether to implement them into their protocols in addition to or in place of existing medications. Often, an update may not be necessary at all.
“We’re always looking for new drugs that might help,” said Daggett. “We evaluate new drugsas a team, and decide whether they have a role at our hospital.”
Saagar Akundi, Pharm.D., clinical pharmacy manager at Bayshore and East Houston Regional medical centers, agreed. He and his team continually evaluate new drugs based on effectiveness data.
Annually, many hospitals carefully review and compile data detailing the percentage susceptibility of a particular organism to a particular drug. They present this information — called an antibiogram — to physicians in an easy-to-reference form, so physicians have information at their fingertips.
In addition to the monthly, bi-monthly or quarterly examinations of antibiotic protocols, successful programs get even more granular and ensure that individual cases are being handled properly, according to the defined protocols.
At Midland Memorial, smaller groups meet regularly to evaluate particular patients and make necessary adjustments on a case-by-case level. “Pharmacists and infectious-disease physicians sit down twice a week,” Daggett said. They look at cases that meet certain criteria “and make recommendations on switching to a different antibiotic, a different dose or stopping antibiotics altogether.”
When lab results come back, taking a time out is important, Kendrick said. “You’ll have a more complete picture of the patient’s illness, and you can reassess whether the patient is on the correct type and dose of drug.”
Akundi agrees. “We review all the antibiotics that are ordered 48 to 72 hours after a patient is put on an antibiotic,” he said. “We look at the cultures and narrow or broaden the antibiotic. If possible, we de-escalate the antibiotic, following specialized recommendations.”
“We’re always looking for a bug-and-drug match,” he said.
Imperative to act
There is no longer any question as to whether hospitals should implement an antibiotic stewardship program, hospital leaders agreed.
And though a CDC study found that antibiotic use in U.S. hospitals did not change from 2006 to 2012, “many hospitals did not have antibiotic stewardship programs until more recently,” said Hicks. As more programs come online, said Hicks, the CDC will continue to “monitor trends in antibiotic use across the spectrum of health care.”