Follow these tips to start an antimicrobial stewardship program

Go for low-hanging fruit first

Hospitals that invest in an antimicrobial stewardship program might expect to see some safety, health care quality, and even long-term financial benefits from their staffing investment.

But what would be the best way to operate such a program? An expert offers these suggestions:

1. Go for low-hanging fruit first. When hospitals hire a pharmacist to help lead an antimicrobial stewardship program, there are several initiatives that would bring about the most efficient changes first.

One such initiative is to focus on patients who are transferred to the hospital with health care-acquired pneumonia (HCAP) or ventilator-associated pneumonia (VAP), suggests Rob Owens, PharmD, co-director of the antimicrobial stewardship program at Maine Medical Center.

"The typical patient might come in sick and be put on three antibiotics," Owens says.

The goal is to hit the disease quickly and potently because it takes several days to find out precisely what the infecting pathogen is via culture and susceptibility results.

But the problem is that once the lab results return, clinicians often continue treating the patient with the three antibiotics, which tend to cause the potential for greater adverse drug events as well as not being cost-effective. And they often will continue the costly regimen for several extra days or even weeks, despite recent national guidelines calling for shorter treatment courses, Owens explains.

A pharmacist who specializes in antimicrobials can play a role in reviewing these cases and making a recommendation to the physician about which antimicrobials should be discontinued after a few days because they will provide the patient no additional medical benefit and might produce unnecessary adverse effects, Owens says.

Also, it is the role of the pharmacist to educate physicians about the latest research and how it emphasizes the need to stop antibiotics when they are no longer needed, as well as to offer dosing suggestions to optimize the pharmacokinetics/pharmacodynamics of the antimicrobials.

"If you continue all those antibiotics in the face of having a culture result on day 3, suggesting that only one is necessary, then that's a good example of having excess antibiotic use," Owens says.

Owens, along with an infectious diseases physician, review antibiotic use in a hospital that has more than 150 patients on antibiotics on any single day.

When they find cases where antibiotics are continuing to be used unnecessarily, they'll point this out and assist physicians in changing prescriptions. This oversight has helped to save the hospital a documented hundreds of thousands of dollars, Owens says.

"Doctors don't put people on antibiotics just to put them on antibiotics," Owens says. "They typically have some suspicion of infection, but that suspicion may go away sometimes, and the antibiotics do not."

Plus, physicians often have a dozen or more medical issues to review with any given patient, and antibiotic use is at the bottom of their priority list, he adds.

"My job is to elevate that problem to No. 1 and put antibiotics on our radar screen," Owens says.

2. Be the antibiotic point person. Hospitals continually need to be on the lookout for development of drug-resistant bacteria, and this is another area where an antimicrobial steward can take the lead.

Although it's a good policy for hospitals to follow guidelines and discontinue antibiotics at eight days, it's also important to be mindful of the handful of cases when antibiotics need to be continued.

"You need to know the patient is clinically responding before you tap the doctor on the shoulder and say, 'We should consider stopping therapy because we have reached the antibiotic duration that is recommended, and the patient has clearly responded to therapy,'" Owens says.

The goal is to emphasize short-course treatment, optimize the dose according to the patient's renal function or according to the pathogen that's been isolated, and keep patient safety as the chief goal at all times, Owens explains.

An infectious diseases-trained pharmacist can be the person physicians turn to when they have questions about drug interactions, antibiotic resistance, and side effects, Owens adds.

Antimicrobial stewards also need to be physicians' teachers and reminders about antibiotic use. There might not be time to make recommendations for every single patient receiving antibiotics, but if the pharmacist spends time to educate clinicians and emphasize the most recent guidelines on the subject, then the hospital's overall antibiotic use will improve.

Reminding physicians and teaching them how to improve antibiotic use extends the antimicrobial steward's reach, Owens notes.

"My job is to help educate people so they can do this for themselves and we don't have to intervene," he adds.

3. Help reduce antibiotic initiations when treatment isn't medically necessary. Residents and other physicians sometimes will start patients on antibiotics solely because of a culture finding, and it's the job of the infectious diseases-trained pharmacist to suggest a different course of action.

For example, sometimes patients have asymptomatic bacteriuria — a symptomless patient with a positive urine culture, Owens says.

Physicians might ask Owens what they should use to treat those cases.

"I back up and say, 'Does the patient have symptoms? Does the patient have a temperature and white blood cell count or dysuria?'" Owens says.

He also asks the doctor why the urine culture was obtained.

Often he finds that the bacteria are present but the patient is asymptomatic, and so there is no need for treatment at all, Owens explains.

"The lab result comes back, and they say 'We should treat this because there are lots of organisms in there,' and it's a reflex where clinicians forget to ask if the patient has symptoms," Owens says.

"You shouldn't be treating asymptomatic bacteriuria," Owens adds. "There are a few exceptions, but for the most part there are very minor numbers of people who need to be treated for it."

Unfortunately, many hospitals and physicians do treat patients with asymptomatic bacteriuria, and this can become a safety issue.

Owens has heard of a cautionary tale where a patient was treated unnecessarily with an antibiotic and developed a very rare side effect that led to renal failure.

"This is an area where we need to start making an improvement," Owens says.

4. Provide continuous attention and education. Since Maine Medical Center started its antimicrobial stewardship program, there have been periods where Owens' intervention in cases occurred infrequently, and there have been periods when he's had to assist with many cases.

"If you're not there doing it every day and reminding people about antibiotic stewardship, they regress to their normal practice," Owens says.

"With our approach, we find that people like our advice and learn from it, but if you're not there doing it for a period of time, it's human nature to go back to their old style of doing things," Owens adds.