Hospitals can play an important role in addressing one of the most urgent public health problems today: the misuse and overuse of antimicrobials. An effective antibiotic stewardship program requires significant commitment from top executive levels down to the bedside.
Antimicrobial stewardship promotes the appropriate use of antibiotics and other antimicrobials. The goal is to reduce microbial resistance and simultaneously improve patient outcomes by decreasing the spread of infections caused by multidrug-resistant organisms, says Linda Greene, RN, MPS, CIC, FAPIC, president of the Association for Professionals in Infection Control and Epidemiology (APIC) in Arlington, VA, and manager of the infection prevention program at University of Rochester Highland Hospital in Rochester, NY.
Antibiotic resistance is a major public health threat. It is estimated that in the United States, antibiotic-resistant bacteria infect 2 million people annually, says Katherine Fleming-Dutra, MD, medical officer with the Office of Antibiotic Stewardship at the federal CDC in Atlanta. At least 23,000 people die as a result.
“Antibiotic use is a major driver of antibiotic resistance, and antibiotic stewardship is the effort to measure and improve antibiotic use. The goal of antibiotic stewardship is to combat antibiotic resistance and to improve healthcare quality and patient safety,” Fleming-Dutra says. “Improving antibiotic use through antibiotic stewardship can lead to decreased antibiotic resistance and prevent avoidable antibiotic adverse events, such as allergic reactions and Clostridium difficile infections, [which are] sometimes deadly diarrheal infections. Effective antibiotic stewardship can also help decrease healthcare costs.”
Antimicrobial-resistant organisms are associated with longer, more expensive hospital stays and poor outcomes, including increased risk of death. (APIC offers a number of resources for antibiotic stewardship online at: http://bit.ly/2ylAyyV.)
CDC and CMS Team Up
Improving antibiotic prescribing and use is part of the CDC’s comprehensive approach to combat antibiotic resistance. The CDC also works closely with the Centers for Medicare & Medicaid Services (CMS) to promote the principles of antibiotic stewardship by providing direct technical assistance in hospitals nationwide to implement these programs within their acute care institutions.
For instance, as of September 2017, the Hospital Improvement Innovation Networks (HIINs) recruited more than 4,040 hospitals nationwide, working with them to improve the quality of care provided to patients. An essential element of their work is targeted at the implementation and strengthening of antibiotic stewardship programs based on the CDC’s Core Elements for Hospital Antibiotic Stewardship Programs, Fleming-Dutra says.
“Technical assistance is provided to these hospitals at a local level through engagement with a wide array of clinical staff inclusive of quality improvement specialists, infection preventionists, and pharmacists, as well as hospital leadership to reduce overall patient harm,” Fleming-Dutra says. “This includes directed assistance to reduce infections associated with antibiotic misuse and/or overuse, like Clostridium difficile and other multidrug-resistant organisms. The HIINs work to assist the hospitals in overcoming challenges by utilizing and spreading best practices that contribute to the achievement of the triple aim.”
Hospitals Can Improve Stewardship
Infection control professionals have been promoting antibiotic stewardship for years, but hospitals have not always adopted it with the same passion, Greene says. Fleming-Dutra notes that the CDC recommends all acute care hospitals implement antibiotic stewardship programs in response to the urgent need to improve antibiotic use. CDC’s Core Elements of Hospital Antibiotic Stewardship Programs outlines the components needed for an effective hospital antibiotic stewardship program.
That’s where quality professionals can help, Greene says.
“This is a major initiative, but when you think about quality, costs, and potential threats in a potential hospital or healthcare organization, you have some very significant issues that compete for attention and resources,” Greene says. “The proper and judicious use of antibiotics is an issue that requires attention because it can affect patients and overall quality of care in far-reaching ways.”
The current hospital quality assurance and performance improvement (QAPI) conditions of participation require that the hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for the QAPI program. Fleming-Dutra notes that the proposed infection control and antibiotic stewardship conditions of participation would require the hospital to:
- appoint a qualified infection control professional as the leader of the infection control program and a qualified medical professional as the leader of the antibiotic stewardship program;
- ensure that these leaders meet specific responsibilities for their respective programs;
- ensure that systems are in place and are operational for the tracking of all infection surveillance, prevention and control, and antibiotic use activities in order to demonstrate the implementation, success, and sustainability of such activities;
- ensure that all hospital-acquired infections and other infectious diseases identified by the infection prevention and control program as well as antibiotic use issues identified by the antibiotic stewardship program are addressed in collaboration with hospital QAPI leadership.
Quality and Patient Safety Issue
The primary concern is that overuse of antibiotics encourages the mutation of drug-resistant organisms, the “superbugs” that can be hard to treat in any single patient and difficult to eradicate once they take hold in a hospital or unit.
“We also know that antibiotics are associated with severe diarrheal diseases like Clostridium difficile, which is a huge issue nationwide and which is part of public reporting,” Greene says. “When you look at this from a quality and compliance perspective, especially with value-based purchasing and the data that is involved there, prevention of C. difficile is a very important concern.”
The costs associated with antibiotic use also are of concern, she notes.
“When you put all those things together, it is a quality and patient safety issue that is extremely important,” Greene says. “Unfortunately, over the years this concern has been effectively siloed. Pharmacy and infection control professionals have been working on this for years and there has been an effort to restrict some of the big-gun antibiotics so that they would be used only when truly necessary, requiring infectious disease approval in some cases. Other organizations have required a review of charts by infectious disease specialists to look for opportunities to discontinue or avoid antibiotics with some patients.”
Those efforts have been ongoing for years now, but they often were loosely put together and did not cross all boundaries of a hospital, Greene says. The next step is to encourage hospitals to develop organizationwide programs rather than efforts residing only in infectious disease or infection control, she says.
Bedside Nurses Play Major Role
The basis of antibiotic stewardship is providing the right dose of the right antibiotic at the right time, but Greene says that involves much more than just the pharmacist or physician writing the prescription.
“The bedside nurse, for instance, is a big part of that program, and people didn’t really think about that recently,” she says. “If I’m the first person assessing that patient and I don’t get the right information regarding their history or allergies, that could make a difference in what the doctor orders. Or, if I’m not timing my antibiotics appropriately and I lose IV access, or if the nurse sends cultures when they’re not necessary because there are no clinical symptoms, the bedside nurse can have a significant impact on antibiotic use.”
Unnecessary cultures are a good example of how a well-meaning nurse or physician can increase the use of antibiotics with no benefit to the patient, Greene explains. Everyone has organisms living on the skin but not necessarily causing infection, but sending a culture to the microbiology lab can produce a report that tells the doctor the patient has a high concentration of staph. The doctor then prescribes an antibiotic, trying to be prudent and respond to admonitions about infection control.
“There are so many things that even the bedside nurse does that have not been appreciated as an important part of this stewardship,” Greene says. “A good antibiotic stewardship program ties all this together in the realization that this is not one person’s role. It’s everyone’s role to make sure we are doing the best for patients from admissions through discharge.”
Need C-suite Support
A hospitalwide antimicrobial stewardship program will require leadership support from the C-suite on down, Greene says. There must be administrative support for appropriate laboratory staff, for instance, and there must be accountability across all parts of the organization.
There also must be a designated leader for the effort, Greene says. That usually will be a pharmacist or physician who champions the effort across all departments and who can be the focal point for questions and problems that may arise, she says.
That leader will be the one to push specific initiatives such as evaluating how often you order antibiotics or the adoption of an antibiotic timeout. This leader also will spearhead reporting, data tracking, and accountability.
“Quality professionals play an important role because they often are very influential in helping an organization set goals and come up with scorecards or quality goals,” Greene says. “At my own organization and most others, there is someone from the quality improvement department on these antibiotic stewardship boards because they have that high-level view of the organization and know how to drive efforts toward a stated goal.”
Education is another area in which quality professionals can play an important role, Greene says. This can be a particular concern with hospitals that see a lot of turnover with interns, residents, and other clinicians, she says. That is why it is important to have much of the antibiotic stewardship program hardwired into the system so that resources and policies are consistent as people come and go, Greene says.
The electronic medical record can be used to keep antibiotic stewardship consistent, with prompts and data entry requirements, for instance. Ongoing education also is key, Greene says.
Measure Outcomes With Antibiograms
Measuring progress and results is another area where quality professionals can contribute, Greene says. The CDC offers an antibiotic use module and an antibiotic resistance module that can be useful, but Greene notes that they require electronic data capture with an automated infection surveillance system.
“You can pull information out of those modules, like days of use and daily dosages — the things that will give you a good perspective,” she says. “If you’re using an inordinate amount of the medications intended only for the sickest patients, you might stop and look at that to figure out why. A key element of antibiotic stewardship is using the most narrow spectrum coverage that is effective. You don’t want a ‘gorilla-cillin’ when a regular penicillin will do.”
CDC recommends that hospitals track and report antibiotic use and outcomes, such as C. diff infections and antibiotic resistance, to measure the effect of interventions to improve antibiotic use, Fleming-Dutra says.
At the national level, CDC tracks antibiotic use and progress in implementation of antibiotic stewardship. (More information can be found in CDC’s Antibiotic Use in the United States, 2017: Progress and Opportunities, available online at: http://bit.ly/2husPnF.)
Measuring outcomes is critical, particularly in the form of an antibiogram, a periodic summary of antimicrobial susceptibilities of local bacterial isolates submitted to the hospital’s clinical microbiology laboratory.
Antibiograms are used to assess local susceptibility rates and in monitoring resistance trends over time within an institution, Greene explains. They also can be used to compare susceptibility rates across institutions and track resistance trends.
“The antibiogram tells you specifically about your institution’s experience, such as your resistance to drug A from certain organisms, or your rates for diarrheal disease, whether they are going up or going down,” Greene says.
Gap Analysis Is Useful
Greene also recommends conducting a gap analysis with the following questions: Do I have someone responsible for antibiotic stewardship? Is leadership giving me the resources for this? Do I monitor in real-time, and measure outcomes?
“It is always good to know where you stand at the moment. If you’re wondering whether you’re really devoting the right effort to antibiotic stewardship, do that kind of gap analysis and see what you’re currently doing and where you might put more emphasis,” she says. “It’s possible that you have much of this in place already, but it’s just not organized under one umbrella and maybe you don’t have one person who is bringing it all together and taking responsibility.”
- Katherine Fleming-Dutra, MD, Medical Officer, Office of Antibiotic Stewardship, Centers for Disease Control and Prevention, Atlanta. Phone: (800) 232-4636.
- Linda Greene, RN, MPS, CIC, FAPIC, President, Association for Professionals in Infection Control and Epidemiology, Arlington, VA. Phone: (202) 789-1890.