Antimicrobial Stewardship Efforts Advance in US Health Systems

JULY 12, 2015
Ashley Marx, PharmD, BCPS
Recently released action plans detail procedures to combat antimicrobial resistance.
US health systems are taking stock of opportunities to adopt and enhance antimicrobial stewardship programs following a recent executive order from President Obama,1 from which came the 5-year National Action Plan for Combating Antibiotic-Resistant Bacteria.2 The order directed the secretary of Health and Human Services to propose regulations by the end of 2016 requiring US inpatient facilities to “implement robust antibiotic stewardship programs that adhere to best practices.” The President’s Council of Advisors on Science and Technology recommended that antimicrobial stewardship programs should be mandated as a Condition of Participation (CoP) for the Centers for Medicare & Medicaid Services (CMS) for inpatient and long-term care facilities by the end of 2017.3

The One-Health Approach
The release of the action plan in March 2015 coincided with the release of the World Health Organization’s draft global action plan on antimicrobial resistance.4 The aim of these actions is to preserve the activity of antimicrobial therapies for all people to ensure successful treatment and prevention of infectious diseases. Both policies cite a “one-health” approach, which is quickly becoming a new buzzword in public health circles and seeks to link human and veterinary medicine with bacteriology and the environment. The term “one-health” recognizes (1) that antibacterial therapy in an individual human or animal affects the community (locally and globally) due to the frequent transmission of resistance factors among bacterial species and (2) that negative consequences of antimicrobial resistance affect patients and their families, agriculture, pharmaceutical companies, and economies. Other key components of these action plans include increasing surveillance efforts to track and study antimicrobial usage and resistance, limiting the use of antimicrobials in agriculture, and promoting research and development of both new antimicrobials and rapid diagnostics for infectious diseases.

California is the only state that has mandated antimicrobial stewardship programs in acute-care hospitals. Its law previously required acute care facilities to evaluate the judicious use of antimicrobials. As of July 1, 2015, however, stewardship programs must also (1) follow professional and society guidelines, (2) establish a physician- led multidisciplinary committee or work group for antimicrobial stewardship, (3) have 1 physician or pharmacist on the committee who is knowledgeable about antimicrobial stewardship, and (4) report program activities to the hospital committee undertaking quality improvement activities.5 This additional legislation seeks to better define antimicrobial stewardship and elevate the quality and consistency of stewardship activities in acute care hospitals. It is too early to assess outcomes of the California Antimicrobial Stewardship Initiative, but collaboration among hospitals of all sizes, focused educational sessions, and creation of a statewide antibiogram will likely yield continuing benefits to the state.

What might a nationally mandated antimicrobial stewardship program look like? The best insight may be provided by results from this year’s version of the CMS infection control survey, which is performed to determine whether CoP standards are met. Several questions about antimicrobial stewardship practice at the facilities surveyed were added for information-gathering purposes only (with no resulting penalty or citation). The survey elements include hospital policies and procedures dedicated to improving antimicrobial use in the facility, a designated leader (physician or pharmacist) who is accountable for stewardship program outcomes, and programs to monitor antimicrobial use within the facility.

In addition, the survey aims to document progress on major tenets of the Centers for Disease Control and Prevention (CDC) Get Smart for Healthcare campaign; requires prescribers to specify the indication, dose, and duration of antibiotic orders; and provides a mechanism for an “antibiotic time-out,” whereby all providers can review the appropriateness of antimicrobial therapy after 48 hours of therapy.6 Based on the history of CMS informational survey elements later becoming requirements, it is likely that these will form the future process measures for antimicrobial stewardship in inpatient facilities. Bottom line: antimicrobial stewardship is coming to your health system, if it isn’t already there.