The nation’s leading infection control associations have reaffirmed their contention that infection preventionists and healthcare epidemiologists are critical to the success of antibiotic stewardship efforts.
In updating their 2012 joint position paper, the Association for Professionals in Infection Control and Epidemiology (APIC) and the Society for Healthcare Epidemiology of America (SHEA) were joined by the Society of Infectious Diseases Pharmacists (SIDP).
That rounds out a full team, every element of which is necessary if antibiotics are to be reined in, and infections identified rapidly if they cannot be prevented.
Indeed, these forces are “intrinsically linked,” said lead author Mary Lou Manning, PhD, CRNP, CIC, FSHEA, FAPIC, in a statement.
“The vital work of infection prevention and control and antibiotic stewardship cannot be performed independently.”
In the years following the last paper, there have been major national developments and increasing regulatory attention on the rise of antibiotic-resistant pathogens and the need for prudent use of antibiotics to stem the tide.
A series of national “watershed events” has raised awareness about antibiotic stewardship, including public health reports and presidential commissions that sounded the alarm.
The most important of these actions may be one that is not yet finalized.
The Centers for Medicare & Medicaid Services (CMS) has proposed new requirements for participation by hospitals that would require antibiotic stewardship programs.
Although the measure has yet to be finalized, it is seen as inevitable.
“Effective in 2016, the CMS requires long-term care facilities to update their IPC program, including requiring an IPC officer in 2019, and an AS program that includes antibiotic use protocols and a system to monitor antibiotic use to be implemented in 2017,” APIC and SHEA reminded readers in the paper.
In addition, The Joint Commission (TJC) has adopted an antibiotic stewardship standard for hospitals.
TJC standard MM.09.01.01, effective Jan. 1, 2017, requires hospitals to establish stewardship programs based on current scientific publications, and to form a multidisciplinary team that includes IPs.
“If you can’t be accredited by either CMS or the Joint Commission, you will not have access to patient [reimbursements],” says co-author of the paper, Edward Septimus, MD, FIDSA, FACP, FSHEA, medical director of infection prevention and epidemiology at HCA Healthcare in Houston. “Then, of course, we have value-based purchasing, where if you are in a lower quartile you may lose 1% or 2% as time goes. It really hits the hospitals’ bottom line.”
These factors are major incentives for antibiotic stewardship, which is one of the best clinical interventions to reduce the selection of resistance and reduce the scourge of Clostridium difficile.
“There is no question that having a regulatory lever helps to heighten awareness and convince the C-suite that this is a value-added to the institutions,” he says.
The human costs have been previously estimated by the CDC, but the toll likely has more than doubled by now, Septimus says.
“The CDC report that came out in 2013 talked about information from 2008,” he says.
“They estimated there were 23,000 people that died of [multidrug-resistant organisms annually]. More recent estimates are probably closer to 50,000.”
The CDC also determined conservatively that resistant infections lead to direct healthcare costs of $20 billion.
“That is the business case,” he says. “But the business case for me is really to provide better, safer care.”
“It’s true you can talk about cost avoidance, but those resources are already being spent,” he adds. “If you prevent infections or you pick them up early so you don’t have transmission to other patients, you have better throughput of patients. It is throughput and revenue that are really the big drivers.”
The Presidential Advisory Council on Combating Antibiotic-Resistant Bacteria previously convened a forum emphasizing the one-health aspect of the problem, meaning it includes human, animal health, and farm use of antibiotics.
“We have to look at the interaction between humans, animals, and the environment,” he says.
“In India, the New Delhi NDM organisms are in streams and drinking water. What we feed animals gets excreted and gets into topsoil and streams.”
The value of infection control to antibiotic stewardship is, in essence, no longer a subject of discussion and the failure to include it is no longer an option.
- Manning L, Septimus EJ., Dodds LS. APIC/SHEA/SIDP Antimicrobial Stewardship Position Paper. Antimicrobial stewardship and infection prevention – leveraging the synergy: A position paper update. Am J Infect Control 2018; 46(4). DOI: https://doi.org/10.1016/j.ajic.2018.01.001.