Relatively ignored during the first wave of antibiotic stewardship initiatives, small, rural critical access hospitals are the focus of new CDC guidelines designed to stop the rise of multidrug-resistant pathogens.

“In our discussions with folks who work in critical access and rural hospitals, they point out that, historically, there has been a misperception that antibiotic overuse and problems like Clostridium difficile and MRSA were only seen in larger hospitals,” said Arjun Srinivasan, MD, associate director of the CDC’s Healthcare Associated Infection Prevention Program. “They pointed out that there are some structural barriers that have to be overcome. There is limited access to infectious disease clinicians, and they also point out very accurately that previous recommendations have really ignored the realities of critical access hospitals.”

“No more,” said Srinivasan, who reviewed the new guidelines for critical access hospitals at a recent CDC webinar. (See recommendations, page 6.) The CDC guidelines are based in part on feedback from critical access hospitals that have adopted all seven of the CDC core measures for antibiotic stewardship.

Small hospitals essentially have the same incentives to prevent misuse and overuse of antibiotics as large ones: prevent C. diff infections that arise as a byproduct of overzealous administration of broad spectrum drugs; implement good clinical practices that result in better patient outcomes; and reduce the rising tide of multidrug-resistant pathogens. There now are infections being reported that are not susceptible to any antibiotics or can only be treated with drugs with bad side effects, such as colistin. The CDC estimates that 2 million people are infected with antibiotic-resistant pathogens annually, and 23,000 die. C. diff, which often appears after antibiotics wipe out commensal bacteria in the gut, causes some 500,000 infections and 15,000 deaths in the U.S. each year.

In addition, antibiotic resistance increases the risk of surgery by thwarting prophylaxis and making surgical site infections harder to treat. In particular, a formidable array of gram-negative bugs has emerged, both resistant themselves and some carrying plasmids that can transfer resistance to other bacteria.

“A growing number of critical access hospitals are now encountering infections caused by highly resistant gram-negative pathogens,” Srinivasan said.

In 2015, only 1.7% of critical access hospitals reported infections due to highly resistant gram-negative pathogens. In 2016, that figure climbed to 2.9%, and the CDC clearly is concerned about the direction the trend is going.

“The percentage of hospitals nearly doubled in the course of the year, so this is certainly an issue that critical access hospitals or rural hospitals are facing,” Srinivasan said.

Proportionally, critical access hospitals use antibiotics about as much as larger hospitals. Reviewing data reported by hospitals to the antibiotic module in the CDC’s National Healthcare Safety Network (NHSN), Srinivasan said hospitals with fewer than 25 beds, 26-50 beds, and more than than 50 beds all are using antibiotics at about the same rate.

“That would be fine if all of that antibiotic use was absolutely necessary,” he said. “But we know from many studies that about 30% of all antibiotics used in hospitals are either unnecessary or inappropriate. So, about a third of that use could simply be eliminated. The antibiotics are being given for longer than they are needed, to treat non-bacterial viral infections, or they are given to treat colonization rather than infection.”

The CDC created core elements for antibiotic stewardship programs for hospitals, nursing homes, and outpatient settings. In NSHN surveillance data for 4,781 hospitals in 2016, 70% of acute care hospitals had all seven measures in place, and large hospitals of more than 200 beds had 82% compliance with all measures.

“Small hospitals and critical access hospitals of less than 50 beds have the lowest rate of implementation compared to the larger hospitals,” he said. “But at the same time, stewardship can be done, and is being done all over the country. In 2016 in our NHSN survey, there were 801 critical access hospitals reporting data, and 211 [26%] reported that they had implemented all seven of the core elements.”

In another important development discussed at the meeting, the Medicare Beneficiary Quality Improvement Program (MBQIP) implemented new antibiotic stewardship requirements for critical access hospitals beginning in 2018, said Yvonne Chow, MPP, project coordinator for MBQIP at the Federal Office of Rural Health Policy.

“Because of the importance of antibiotic resistance, we decided to add a new core element to the program,” she said. “Starting in 2018, we are requiring that every critical access hospital that is participating in the MBQIP program fully implement a hospital antibiotic stewardship program following the CDC seven core elements by Aug. 31, 2022.”

That is in line with the MBQIP program goal of improving the quality of care provided in critical access hospitals by increasing quality data reporting.

Offering a perspective from a small hospital that has adopted stewardship measures was Marc Meyer, RPh, BPharm, CIC, FAPIC, a clinical pharmacist at Southwest Health System in Cortez, CO. Consisting of 25 beds and 10 clinics, the system serves about 50,000 people in rural southwest Colorado and in parts of bordering states, including Ute and Navajo reservations.

Antibiotic stewardship and infection control need to be seen as inseparable sides of the same coin, Meyer emphasized.

“Things considered traditional infection control jobs certainly fit into stewardship,” he said.

These include tracking of drug-resistant pathogens; handwashing education and monitoring; chlorhexidine use in surgery for high-risk patients; infection control bundles for VAP, BSIs, and CAUTIs; C. diff testing and education; and family/patient antibiotic use education, he said.

When beginning a stewardship program, ensure administration is on board and be ready to provide regular updates, he advised. Some initial steps include forming a stewardship team and creating antibiograms to inform drug use and clarify local patterns of susceptibility and resistance. Choose an antibiotic class to monitor and look at ways to restrict your formulary, he said.

“For your first attempts — if you haven’t started a program — I would recommend you go slow,” Meyer said. “Make sure your first project is successful.”

Some suggested first projects can include monitoring new antibiotic IV starts, tracking monthly drug costs, using antibiotic “timeouts” to reassess therapy, and daily rounding by a stewardship team, he recommended.

REFERENCE

1. CDC. Implementation of Antibiotic Stewardship Core Elements at Small and Critical Access Hospitals. 2017. Available at: http://bit.ly/2kvGIGV.