A CMS proposed regulation requiring antibiotic stewardship in hospitals still is in limbo, but hospitals increasingly are adopting the programs due to new accreditation requirements by The Joint Commission.
“There is a possibility that [CMS rule] may eventually happen, although we don’t know yet whether that will be moved forward to a full regulation,” says Lauri Hicks, MD, director of the Office of Antibiotic Stewardship at the CDC. “So, at this point in time I think the good news is there are other levers that are in place to encourage uptake of stewardship programs in hospitals. The one I think that is having a major impact is the new standard from The Joint Commission.”
Adopted in 2017 and now effective for all hospitals and nursing care centers, The Joint Commission Medication Management (MM) standard MM.09.01.01 requires antimicrobial stewardship programs. The standard essentially codifies the CDC stewardship core elements of leadership commitment, accountability, drug expertise, action, tracking, reporting, and education.
“It requires that hospitals have stewardship programs meeting their criteria, which are in sync with the CDC core elements,” Hicks says. “This is a standard that is required for Joint Commission accreditation. So, I think that has been a very powerful lever, and we will see more stewardship uptake in hospitals in the coming years.”
Meanwhile, there is a CMS requirement in effect for nursing homes to establish antibiotic stewardship programs, so the CDC is focusing on that segment of the healthcare system as well.
“We are doing a point-prevalence survey right now trying to better characterize how antibiotics are being used in nursing homes,” Hicks says. “From past studies as well as the initial pilot study that we did, we’ve learned — and this is not a surprise to people who work in long-term care — that antibiotics are often used for patients who have asymptomatic bacteriuria, a positive urine [sample] in a patient who does not have symptoms. In that scenario, we think that there are a lot of antibiotics used in nursing home patients that are completely unnecessary.”
There also is a lot of unnecessary antibiotic use in nursing homes for residents with respiratory infections, she adds.
“There is probably some [inappropriate] treatment of viral infections like we see in outpatient settings,” Hicks says. “But it is not just about making sure that patients don’t get antibiotics when they are not needed. It is also about making sure that when an antibiotic is needed that the nursing home patient gets the right drug for the right bug. We are looking for opportunities to optimize antibiotic use in this population.”
As part of this, the CDC is reaching out to various professional organizations for physicians who prescribe drugs in long-term care, underscoring the need for antibiotic stewardship.
“We’re providing those organizations with CDC messaging to get to those providers,” she says. “We’re also working with CMS to make sure messaging to facilities is consistent. We’re supporting the work that is being done through the CMS Quality Innovation Networks and their Quality Improvement Organizations. They have these organizations all across the country, and we are getting information out to those networks through our state health department partners.”
Acute care hospitals can report key antibiotic use data to the CDC’s National Healthcare Safety Network.
“We don’t have anything comparable for nursing homes at this stage,” Hicks said. “Having said that, we are very engaged with a number of different companies and organizations to look at the options for capturing data in nursing homes. We are about to have another meeting with a lot of these partners to identify the options for reporting antibiotic use nationally.”
In another development on the antibiotic stewardship front, the Society for Healthcare Epidemiology of America (SHEA) recently held a workshop in Chicago to strategize best approaches to antibiotic stewardship programs.
“We need better ways to assess what we are doing to help identify best practices and help ensure widespread dissemination of them,” says Elizabeth Ashley, PharmD, MHS, co-chair of the SHEA Antimicrobial Stewardship Research Workshop. “One of the biggest challenges that people have is to get enough resources to do the work that is needed to support what is out there. We need to get more science across the board, and continue to expand education to patients and families, who are an important element of how to best prescribe antibiotics.”
The SHEA workshop included speakers who specialize in the sociological sciences. Some of them discussed factors that influence human behavior and keys to implementing change.
“In addition to just having measures for changes in antibiotic use, we are looking at implementation science — why certain interventions are more accepted than others,” Ashley says. “Really, what are the sociological drivers behind antibiotic prescribing? This is really what you need to get to the root of if you are going to change practice, particularly broad sweeping changes in practice.”
For example, discussions included the social science of ethnography, which involves conducting very structured interviews and compiling that data into common themes and perceived barriers, she said.
“That gives very valuable information back to the stewardship team, so they can design interventions that are going to better meet the needs of providers,” Ashley says. “Just telling someone they need to use less antibiotics — they might know that. But we don’t really know all of the reasons behind their antibiotic prescribing. [Understanding what] drives antibiotic prescribing is essential for us to design interventions that are going to change that. It’s very labor-intensive work, but very valuable work.”