Antibiotic Stewardship Programs

Hospitals are being encouraged to develop infection prevention programs as part of a National Action Plan

The Obama Administration’s “National Action Plan for Combating Antibiotic-resistant Bacteria,” issued March 2015, calls for all hospitals to establish antibiotic stewardship programs to optimize the treatment of infections and reduce adverse events associated with antibiotic use, including antibiotic resistance.

It’s a tall order.
The healthcare industry as a whole is “not close at all” to the plan’s ambitious goal, says Vicki G. Allen, MSN, RN, CIC, infection prevention coordinator at Beaufort (S.C.) Memorial Hospital, and vice chair of the communications committee of the Association for Professionals in Infection Control and Epidemiology (APIC). Still, the plan may make an impact.

“I think the National Action Plan has increased the awareness and urgency that hospitals and healthcare facilities need to get on board in an effort to address this crisis within their own organizations,” says Allen. “Just as the public reporting of healthcare-associated infections and events along with penalties has increased the awareness and forced changes within organizations, I believe the same will be true in regards to antibiotic stewardship. The expectations from the public and regulatory agencies has provided the incentive for organizations to make changes within this patient safety arena.”

Gina Pugliese, RN, MS, FSHEA, vice president of Premier Inc.’s Premier Safety Institute, says it is difficult to assess the status of antibiotic stewardship programs, or ASPs, in U.S. hospitals because most of the surveys on the subject are self-reported, and lack validation. “Also, ASPs have many components, and some hospitals may have implemented specific aspects of successful programs, but they do not appear to have what is being referred to as an ASP program. Additional evidence-based research is needed to identify those elements of a program that are the most effective.”

Stewardship programs do not fit under the one-size-fits-all category, she says. “Organizational structure and availability of resources – including human resources and technology – are considerations in constructing a viable ASP.”

In 2014, the Centers for Disease Control and Prevention offered some recommendations.

Leadership
The first step is to identify an overall stewardship program leader, says CDC. Physicians have been effective in this role. The program should also have a pharmacy co-leader.

Program leaders benefit from formal training in infectious diseases and/or antibiotic stewardship, says CDC. Larger facilities have achieved success by hiring full-time staff to develop and manage stewardship programs, while smaller facilities report other arrangements, including use of part-time, off-site expertise and hospitalists.

Key support
The work of stewardship program leaders is greatly enhanced by the support of other key groups when available, says CDC:

Clinicians and department heads. As the prescribers of antibiotics, it is vital that clinicians are fully engaged in and supportive of efforts to improve antibiotic use.
Infection preventionists and hospital epidemiologists coordinate facility-wide monitoring and prevention of healthcare-associated infections and bring their skills to auditing, analyzing and reporting data.
Quality improvement staff can also be key partners, given that optimizing antibiotic use is a medical quality and patient safety issue.
Laboratory staff can guide the proper use of tests and the flow of results. They can also create and interpret the facility’s cumulative antibiotic resistance report.
Information technology staff are critical to integrating stewardship protocols into existing workflow. Examples include embedding relevant information and protocols at the point of care (e.g., immediate access to facility-specific guidelines at point of prescribing), implementing clinical decision support for antibiotic use, creating prompts for action to review antibiotics in key situations, and facilitating the collection and reporting of antibiotic use data.
Nurses can assure that cultures are performed before starting antibiotics. In addition, they review medications as part of their routine duties and can prompt discussions of antibiotic treatment, indication, and duration.

Strategies
Providers should choose interventions based on the needs of the facility as well as the availability of resources, says CDC. The agency categorizes stewardship interventions in three ways: broad, pharmacy-driven, and infection and syndrome-specific.

Broad interventions include:

Antibiotic “time outs.” Antibiotics are often started in hospitalized patients while diagnostic information is being obtained. However, providers often do not revisit the selection of the antibiotic after more clinical and laboratory data (including culture results) become available. An antibiotic “time out” prompts a reassessment of the continuing need and choice of antibiotics when the clinical picture is clearer and more diagnostic information is available.
Prior authorization. Some facilities restrict the use of certain antibiotics based on the spectrum of activity, cost, or associated toxicities to ensure that use is reviewed with an antibiotic expert before therapy is initiated.
Prospective audit and feedback. External reviews of antibiotic therapy by an expert in antibiotic use have been highly effective in optimizing antibiotics in critically ill patients and in cases where broad spectrum or multiple antibiotics are being used.

Pharmacy-driven interventions include:

Automatic changes from intravenous to oral antibiotic therapy in appropriate situations and for antibiotics with good absorption.
Dose adjustments in cases of organ dysfunction (e.g. renal adjustment).
Dose optimization, including dose adjustments, based on therapeutic drug monitoring, optimizing therapy for highly drug-resistant bacteria, achieving central nervous system penetration, extended-infusion administration of beta-lactams, etc.
Automatic alerts in situations where therapy might be unnecessarily duplicative.
Time-sensitive automatic stop-orders for specified antibiotic prescriptions, especially for antibiotics administered for surgical prophylaxis.
Detection and prevention of antibiotic-related drug-drug interactions.

Infection- and syndrome-specific interventions include those for:

Community-acquired pneumonia. Interventions include improving diagnostic accuracy, tailoring therapy to culture results, and optimizing the duration of treatment to ensure compliance with guidelines.
Urinary tract infections (UTIs). Many patients who get antibiotics for UTIs actually have asymptomatic bacteriuria, not infections.
Skin and soft tissue infections. Interventions have focused on ensuring patients do not get antibiotics with overly broad spectra and ensuring the correct duration of treatment.
Empiric coverage of methicillin-resistant Staphylococcus aureus (MRSA) infections. In many cases, therapy for MRSA can be stopped if the patient does not have an MRSA infection or changed to a beta-lactam if the cause is MRSA.
Clostridium difficile Reviewing antibiotics in patients with new diagnoses of CDI can identify opportunities to stop unnecessary antibiotics, which improves the clinical response of CDI to treatment and reduces the risk of recurrence.
Treatment of culture-proven invasive infections. Invasive infections (e.g. blood stream infections) present opportunities for interventions to improve antibiotic use because they are easily identified from microbiology results.

Source: Core Elements of Hospital Antibiotic Stewardship Programs, Centers for Disease Control and Prevention, http://www.cdc.gov/getsmart/healthcare/implementation/core-elements.html