Antibiotic Stewardship

Antimicrobial agents have long been used to treat patients with infectious diseases. These drugs have reduced illness and death from infectious diseases substantially for many years. Unfortunately, antimicrobials have been used so widely and for so long that those infectious organisms have adapted over time to become resistant to some drugs. At least 2 million Americans become infected with antimicrobial-resistant organisms each year, causing more than 23,000 deaths.¹ At least 30% of all antimicrobial use in the United States is unnecessary or inappropriate, leading to resistance.²

Because of the dangerous impact of such resistance, antibiotic stewardship programs (ASPs) have become a requirement for hospitals. Antibiotic stewardship refers to the careful and responsible management of anti-infective agents. The goals of ASPs are to limit inappropriate antimicrobial use, optimize antimicrobial selection, and limit unintended consequences. The most important question is not which antibiotic to use but whether to use one at all. Proper selection considerations include dosing, route of administration, and duration of therapy. Finally, unintended consequences to consider are adverse drug events, cost, and resistance.¹

Leadership Commitment

Leadership collaboration is imperative for a successful ASP. Executives can issue directives, requiring the facility to cooperate with efforts to monitor and improve antibiotic use. Leaders can delegate stewardship-related duties and place these duties into job descriptions and performance reviews. Sufficient compensation, time, and training should be given to those departments participating in the stewardship program.

Accountability

Ideally, ASPs would have an infectious-disease specialist physician as the stewardship program leader responsible for program outcomes and a pharmacist with additional training in infectious diseases as the pharmacy leader to colead the group and be responsible for improving antibiotic use.^3,4

Although large facilities typically have success in hiring full-time staff to develop and maintain ASPs, smaller facilities may use a physician and a pharmacist without extensive training in infectious diseases. The Pharmacy and Therapeutics committee should not be considered the ASP unless it expands its role to allow the time and expense to create and maintain the program.⁵

Drug Expertise

Many departments should be available to support the ASP. The more departments involved, the smaller the workload for each department and the more buy-in staff members in these departments will have. Clinicians and department heads must be fully engaged in the ASP, as they are the prescribers of the antimicrobials.

Infection prevention specialists and hospital epidemiologists coordinate monitoring and prevention of infections. These specialists can analyze, audit, and report data. They can also assist with educating staff members and implementing strategies to optimize antibiotic use.⁶

Appropriate antibiotic use is both a medical quality and patient safety issue. Therefore, the quality improvement staff should be involved to ensure that policies and procedures are being followed. One important policy is documentation of dose, duration, and indication for all courses of antibiotics to ensure that these medications are discontinued or modified as appropriate. One important procedure is the development and implementation of facility-specific treatment recommendations based on formulary options, local susceptibilities, and national guidelines.

Laboratory staff members should guide the appropriate use of tests and expedite results to the proper individuals. They can also create and interpret a site-specific antibiogram (Figure).

Information technology staff members are imperative for the integration of stewardship protocols into workflow. Some examples include creating prompts to review antibiotics at 48 hours, facilitating the collection and reporting of antibiotic use data, implanting information and protocols at the point of care, and implementing clinical decision support.⁷

Finally, nurses can prompt discussions of antibiotic treatment, indication, and duration during their daily review of medication. They can also assure that cultures are performed before beginning antibiotic treatments.⁸

Interventions

Interventions should be chosen based on the needs of the facility, the availability of recourses, and content expertise. It is best not to implement too many interventions at one time. Stewardship interventions are classified as broad, pharmacy-driven, and infection/syndrome specific interventions.

Broad Interventions

Antibiotics are often started empirically while waiting for clinical and laboratory data. Often, these decisions are not revisited to ensure that important questions are answered, such as: Will this infection respond to antibiotics? Is the patient on the correct drug, dose, and route of administration? Can there be de-escalation to a more targeted antibiotic? How long should the patient receive this antibiotic?⁹ Antibiotic treatment should have a “time-out” at 48 hours to answer these questions and make appropriate changes.¹⁰

Some facilities restrict the use of antibiotics through the formulary based on spectrum of activity, cost, adverse events, etc. This intervention would require a prior authorization for restricted medications.

Prospective audit and feedback is an external review of antibiotic therapy by someone not on the treatment team and has shown to be valuable in optimizing antibiotic therapy in critically ill patients receiving broad-spectrum or multiple antibiotics.¹¹

Pharmacy-Driven Interventions

The pharmacy can help provide optimal antibiotic use by creating automatic changes from intravenous to oral therapy in appropriate situations, making dose adjustments in patients with organ dysfunction, optimizing therapy for highly drug-resistant bacteria, alerting when therapy may be unnecessarily duplicative, creating time-sensitive automatic stop orders, and detecting and preventing antibiotic-related drug—drug interactions.¹²

Infection/Syndrome-Specific Interventions

Several infections and syndromes can benefit substantially from having standard interventions to provide prompt and effective treatment. These include: community-acquired pneumonia, urinary tract infections, skin and soft tissue infections, empiric coverage of methicillin-resistant Staphylococcus aureus, Clostridium difficile infections, and treatment of culture-proven invasive infections.

Tracking and Reporting Antibiotic Use and Outcomes

Measurement is crucial to identifying improvement opportunities and assessing the impact of ASP efforts. ASP measurement may involve the appraisal of the process (policies and procedures) and the outcome (has improved antibiotic use improved patient outcomes?).

Measurement of antibiotic use is done as either days of therapy (DOT) or defined daily dose. As part of the National Healthcare Safety Network, the CDC has developed an Antibiotic Use Option that can automatically collect and report monthly DOT data, which can then be analyzed.¹

Clinical outcomes are tracked to measure the impact of interventions to improve antibiotic use. Other outcomes measured include antibiotic resistance and cost savings.¹³

Education/Training

ASPs should provide regular updates on infectious disease management, antibiotic prescribing, and antibiotic resistance to their facilities. This can be done in any variety of ways. Education has been found to be most effective when corresponding interventions and measurements of outcomes are available as examples.⁴

Kathleen Kenny, PharmD, RPh, earned her doctoral degree from the University of Colorado Health Sciences Center. She has 25-plus years’ experience as a community pharmacist and works as a freelance clinical medical writer based in Colorado Springs, Colorado.

References

• Antibiotic/antimicrobial resistance. CDC website. cdc.gov/drugresistance/. Updated August 18, 2017. Accessed December 26, 2017.
• CDC: 1 in 3 antibiotic prescriptions unnecessary. CDC website. cdc.gov/media/releases/2016/p0503-unnecessary-prescriptions.html. Updated January 1, 2016. Accessed December 28, 2017.
• CDC. Core elements of hospital antibiotic stewardship programs. cdc.gov/antibiotic-use/healthcare/implementation/core-elements.html. Updated February 23, 2017. Accessed December 27, 2017.
• Dellit TH, Owens RC, McGowan JE, Jr, 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):159-117. doi: 10.1086/510393.
• Ohl CA, Dodds Ashley ES. Antimicrobial Stewardship programs in community hospitals: the evidence base and case studies. Clin Infect Dis. 2011;53(suppl 1):S23-28. doi: 10.1093/cid/cir365.
• Moody J, Cosgrove SE, Olmsted R, et al. Antimicrobial stewardship: a collaborative partnership between preventionists and healthcare epidemiologists. Infect Control Hosp Epidemiol. 2012;33(4):328-330. doi: 10.1086/665037.
• Evans RS, Pestotnik SL, Classen DC, et al. A computer assisted management program for antibiotics and other antiinfective agents. N Engl J Med.1998;338(4):232-238.
• Edwards R, Drumright L, Kiernan M, Holmes A. Covering more territory to fight resistance: considering nurses’ role in antimicrobial stewardship. J Infect Prev. 2011;12(1):6-10. doi: 10.1177/1757177410389627
• Kaye KS. Antimicrobial de-escalation strategies in hospitalized patients with pneumonia, intra-abdominal infections, and bacteremia. J Hosp Med. 2012;7(suppl 1):S13-21. doi: 10.1002/jhm.983.
• Pardo J, Klinker KP, Borgert SJ, Trikha G, Rand KH, Ramphal R. Time to positivity of blood cultures supports antibiotic de-escalation at 48 hours. Ann Pharmacother. 2014;48(1):33-40. doi: 10.1177/1060028013511229.
• DiazGradados CA. Prospective audit for antimicrobial stewardship in intensive care: impact on resistance and clinical outcomes. Am J Infect Control. 2012;40(6):526-529. doi: 10.1016/j.ajic.2011.07.011.
• Rattanaumpawan P, Morales KH, Binkly S, et al. Impact of antimicrobial stewardship programme changes on unnecessary double anaerobic coverage therapy. J Antimicrob Chemother. 2011;66(11):2655-2658. doi: 10.1093/jac/dkr321.
• Standiford HC, Chan S, TripoliM, Weekes E, Forrest GN. Antimicrobial stewardship at a large tertiary care academic medical center: cost analysis before, during, and after a 7-year program. Infect Control Hosp Epidemiol. 2012;33(4):338-345. doi: 10.1086/664909.