Hospital's antimicrobial education program has five-week themed series

Door posters and tabletop notices are used

Sometimes an antimicrobial stewardship program needs a catchy and short educational series to capture hospital staff's attention.

So The Medical Center of Columbus, GA, used a five-week series on ways everyone could do a better job in antimicrobial stewardship through the use of door posters and table-top tents, says Deanne Tabb, PharmD, MT (ASCP), infectious disease specialist at The Medical Center, which is part of Columbus Regional Healthcare System.

Antimicrobial stewardship programs should be a hospital priority, and everyone in a hospital has some responsibility for making it work. An education program that reaches people from around the hospital, but doesn't involve the resources of inservices, is one way of raising awareness.

Here's how the five-week program works:

Week 1: "We defined why antibiotic resistance is increasing, explaining how there has been overuse of antibiotics and this is associated with worse outcomes," Tabb says. "So we get people engaged about what we need them to focus on."

The educational material provided specific details of what employees can do to help.

Week 2: "We looked at goal initiatives, including how to obtain quality cultures and establish source control," Tabb says.

Other goals might be to write indications for all antibiotics and to set durations of therapy, she adds.

Week 3: The third week of posters were devoted to what an antibiotic is for.

Nurses, physicians, therapists, and others working with patients need to know why a particular drug is being used for a certain patient, Tabb says.

"The person prescribing that antibiotic should follow the patient's clinical response on a daily basis, and at the 72-hour mark ask if they have the right antibiotic," she adds.

The educational material focused on writing clear indications: "How do I know if I get to the chart and there isn't a clear indication?" Tabb says. "Every practitioner, even the nurses, need to know what the indication is."

The posters provided examples of clear indications. For example, one might say, "Write Levaquin® 750 mg orally every day for community-acquired pneumonia," Tabb says.

Providers need to write these in either the order or the progress note so that any practitioner could read that chart and know why that antibiotic was prescribed, she adds.

Week 4: Educational materials focused on setting durations of therapy, following the clinical response.

"Then I give them an example and say, 'Now that your patient is on day 2 of antibiotic therapy and has clinically responded, you need to write another order that says to continue it four more days,'" Tabb explains.

For example, the chart might read that the patient is given levofloxacin (Levaquin®), 750 mg, PO daily times four more days, Tabb notes.

"That's something they're not used to," she adds. "Their habits are not hardwired to write times five or times seven days, so our baseline statistics are really not impressive at all."

Providers were allowing excessive lengths of duration of therapy, Tabb says.

"They might choose the right antibiotic, but they were keeping them on it for too long," Tabb says. "This was a huge opportunity to improve."

Patients often were kept on antibiotics too long because it was easy for providers to lose track of how long a particular patient was on antibiotic therapy, particularly when documentation was on paper, she adds.

"Once you get on computerized physician order entry, then you can hardwire setting durations of therapy," Tabb says.

Week 5: This week's educational message was a reminder not to forget about the cultures.

"This week is devoted to obtaining cultures before antibiotics are administered, if possible," Tabb says. "You can utilize respiratory therapy to get quality sputum cultures or respiratory cultures like in pneumonia."

Sometimes hospital staff will give a patient a cup and ask for a sample, but no one will follow up when the patient cannot produce a sample within the first couple of hours, Tabb explains.

"We encourage them to get respiratory therapy in to assist and help encourage and coach the patient," Tabb says. "We want to grow out the pathogen and fine-tune our antibiotics when we get the pathogen, because if you don't get a good culture then you have to stay on a broad-spectrum antibiotic."

Patients admitted with bacteremia and sepsis needed repeated blood cultures to ensure sterilization of their blood stream, Tabb says.

But there was a high variability of this being practiced.

Need confirmed cultures

"There might not be a confirmation on the chart where someone made sure the patient didn't have persistent bacteremia," Tabb explains. "For organisms like MRSA or for sepsis, you need confirmed cultures at 48 or 72 hours with repeat blood cultures, and those need to be negative before you would feel confident that the patient doesn't have persistent bacteremia while on active therapy."

Without the confirmation, there is no way of knowing how long it will take the patient's blood stream to be clear of infection, she adds.

"For different patients who have the same organism it could take from 24 hours up to seven days," Tabb says. "So this was part of the week 5 education, to remind people to repeat cultures every 72 hours until the cultures were confirmed negative."

Also, the educational session taught employees to not collect surface cultures, which just means there's colonization, she says.

The Centers of Disease Control and Prevention (CDC) has a campaign that advises health care workers not to treat colonizing organisms because they're not actively causing infection, and treating something like that with antibiotics might lead to having a worse problem, Tabb explains.

"The CDC's goal is to prevent antimicrobial resistance in health care settings," she adds.