While most hospitals have moved to put antibiotic stewardship programs in place, experts suggest that a new CMS requirement should go a long way toward ensuring 100% compliance with guidelines for such programs already established by the CDC. Also, the move is seen as a big step against multidrug-resistant organisms and the misuse of antibiotics.
• The primary goal of stewardship programs is to ensure that antimicrobials are used only when they are necessary and right for each specific case. They also are designed to mitigate or decrease the incidence of resistant organisms in hospitals.
• Experts note that stewardship programs have been shown to improve patient outcomes, increase cure rates, and reduce the incidence of adverse events such as Clostridioides difficile infections.
• While large, academic medical centers typically have the resources and expertise to build effective stewardship programs, smaller community hospitals and critical access hospitals in rural areas face many challenges in this regard.
• Intermountain Healthcare is one of several large health systems that have developed outreach programs aimed at helping smaller facilities meet the regulatory requirements for stewardship programs.
The Centers for Medicare & Medicaid Services (CMS) has finalized new requirements for hospitals to establish antibiotic stewardship programs as part of their infection control efforts, leaving no more excuses for facilities that have thus far failed to act.
The move is notable as it is the first federal policy to actually mandate hospital antibiotic stewardship. This is viewed as a big step against multidrug-resistant organisms and the misuse of antibiotics.
There is plenty of room for improvement in this area. The CDC estimates that about one-third of the antibiotic prescriptions written by providers each year are for patients with conditions that do not require these drugs. It is a problem that experts hope will improve under this mandate, although smaller community hospitals and critical access facilities in rural areas may find it challenging to put an antibiotic stewardship program in place.
Push for Improvement
Why push so hard for hospitals to create antimicrobial stewardship programs?
“The primary goal is to ensure that antimicrobials in general are only used when they are necessary and that they are right for [each] particular case,” explains Dan McQuillen, MD, a staff infectious disease physician at Lahey Hospital & Medical Center in Burlington, MA, and the incoming vice president of the Infectious Diseases Society of America (IDSA). “In general, stewardship programs have been shown to improve patient outcomes and increase cure rates because [they help to] get people on drugs that are effective for their infections theoretically faster.”
Further, there are fewer adverse events when a facility maintains an effective stewardship program. Part of the role of such programs is to monitor the use of antibiotics for some of the common adverse outcomes that can happen when those drugs are used, McQuillen notes. For instance, effective stewardship has been shown to reduce the incidence of Clostridioides difficile infections.
By preventing such adverse effects, stewardship programs can shorten lengths of stay in the hospital and reduce overall costs, McQuillen shares.
“The other important effect of a stewardship program is to help mitigate or decrease the incidence of resistant organisms in hospitals,” he explains. “There are plenty of data to show that if you use too-broad antibiotics for too long in patients who don’t need them, you end up with multiple resistant organisms that are really hard to treat and get rid of.”
While developing a stewardship program makes sense, not all hospitals have taken this important step. When the CDC released guidelines on what a comprehensive stewardship program should consist of in 2017, the percentage of hospitals developing the recommended stewardship teams and infrastructure increased from about 48% to more than 70%.1 However, that still left many hospitals without formal stewardship efforts.
This is why IDSA has long pushed for CMS to include creating an effective stewardship program as a condition of participation in Medicare. “This move will hopefully drive [the percentage] of hospitals with stewardship programs to 100%,” McQuillen says. “It is basically taking the CDC construct and making it mandatory. If you want to participate in Medicare, you have to do this, and that is key.”
In general, stewardship activities involve the regular review of a hospital’s antibiotic prescribing practices by experts in infectious disease. “[A program] will have infrastructure and personnel to be able to collect those data and act on it,” McQuillen notes. “It is just a much more structured, formal way of making sure that stewardship is practiced,” he says.
The problem is that while large academic medical centers typically have the resources and expertise to build such a program, smaller community hospitals and critical access hospitals in rural areas face many challenges in this regard.
Further, McQuillen notes that the pipeline of infectious disease physicians is diminishing, in part because of the financial constraints on people entering the infectious disease field. “There are areas of the country where you’ve got a small hospital that is 100 miles from [a population center], and there is not enough business for an infectious disease physician to work locally there,” McQuillen observes.
To address this problem, many large health systems have developed outreach programs, networks, and telehealth solutions to help smaller hospitals access the expertise and infrastructure they need to improve their antibiotic prescribing practices and meet regulatory requirements.
One example of this is Intermountain Healthcare’s Infectious Diseases Telehealth program. Under this initiative, 17 community hospitals that are part of the Salt Lake City-based health system and two additional hospitals in other states are receiving assistance with antibiotic stewardship, explains Todd Vento, MD, MPH, medical director of the program.
He says the program is somewhat unique in that consultation and advice on infectious disease is tightly integrated with the actual antibiotic stewardship component. “We use telehealth to deliver both of those components,” he explains.
When the program started three years ago, Vento notes that the first order of business was to track how many facilities would be interested in infectious disease telehealth services, along with when and why providers were seeking assistance.
“We tracked that for our first 18 months to get a flavor of what the demand was and where we could find opportunities to help with stewardship programs and improving [antibiotic prescribing] practices,” Vento shares.
More recently, the program has focused on specific, commonly seen conditions to gauge the effect of the program. For example, Vento notes that Staphylococcus aureus bacteremia is one of the most important infectious disease conditions for which it is well known that one can improve outcomes if one consults with an infectious disease specialist.
“We started to look at that ... and our initial findings are that there looks to be a decrease in both 30- and 90-day mortality when we compare cases where the Infectious Disease Telehealth program was on board vs. cases where the program was not on board,” he explains.
The specific effect of the program on the larger issue of antibiotic stewardship may take longer to gauge, in part because the model focuses on establishing a partnership with the participating facilities.
“When we first started the program, we basically did site visits to every facility in our system that we were covering to make sure that they had a local program,” explains John Veillette, PharmD, BCPS, an advanced clinical pharmacist in the Infectious Disease Telehealth program. “We made sure that we identified local champions, [a physician and a pharmacist], who were going to help us evaluate antibiotic prescribing practices at the hospitals.”
This is a critical step because CMS requires hospitals to designate a multidisciplinary team to oversee stewardship activities. “That is step one to meet the requirements: Have dedicated people responsible for looking at [antibiotic prescribing],” Veillette notes. “Then, [Vento] and I have an advisory role where we call in to all of the [team] meetings or we attend the meetings in person to help guide the team members in evaluating their antibiotic use and also looking for opportunities to improve.”
Further, Veillette helps the participating teams and facilities with active surveillance daily. “I use a computer program to identify patients that have the most severe infections, such as patients who have bacteria in their blood or patients who are on multiple broad-spectrum antibiotics,” he says. “I look at those cases on a daily basis to try to identify opportunities to improve.”
Veillette will call hospitals to advise staff on opportunities to optimize antibiotic treatment for those extremely sick patients. “They will also call into me with questions. I serve as a central drug information resource for them and try to identify patients who either need to have their antibiotics improved or changed,” he says. “I also identify patients who need to be seen by an infectious disease clinician.”
Veillette adds that this is a good example of the tie between antibiotic surveillance efforts and infectious disease consultation within the program.
Beyond the daily surveillance and advisement activities, Veillette will assist the participating facilities in reviewing their antibiotic use on a longitudinal basis to try to find opportunities to change prescribing practices and advance care.
“We just did a site visit to one of our critical access hospitals and shared with them some data on how they were managing urinary tract infections [UTI] in the ED and opportunities for improvement there,” he explains.
Vento and Veillette will document all of their regular surveillance and quality improvement efforts for each participating hospital. Then, each facility will receive that information to share with site surveyors or regulatory agencies that come to review antibiotic stewardship activities.
“All of that documentation is put together, and then the hospitals are ready for their regulatory surveys,” Veillette says.
However, Veillette stresses that the Intermountain program serves an advisory role. “One of our central concepts is local empowerment with centralized support and resources,” he says. In other words, specific areas targeted for improvement and final prescribing decisions are made at the local level.
“Sometimes, [a local provider] will want to know what he or she should do in a specific scenario,” Veillette continues. “Dr. Vento will give advice to the physician, and I will give advice to the local pharmacist on how I would approach the situation. The ultimate decision on how to move forward is up to them. We present the information, and we try to keep them up to date on the latest research and guidelines.”
One thing that helps the Intermountain Healthcare facilities is the fact that they are in an integrated system that already has instituted corporate-level stewardship practices and policies, Vento observes.
“That helps to give people boundaries ... beyond that, we can provide them with their data on antibiotic usage and how it compares to other facilities,” he says. “However, they can choose to look at the things they think are important to their facilities.”
A facility may be concerned about three emergency physicians who are using one antibiotic repeatedly in cases in which it is not required. That is the type of situation that will come up in discussions between the local stewardship teams and the telehealth program, Vento notes.
“If they need our help, they will tap into Veillette, and he will help pull case data or central antibiotic use data so they can support their findings and then report back to their medical teams,” Vento shares.
Then, the local stewardship teams can develop policies aimed at treating the specific conditions at issue in a different way, rather than going straight to the antibiotic that is used unnecessarily, Vento adds.
To further support local antibiotic stewardship efforts, Vento and Veillette occasionally will hold grand rounds at a small community hospital to present cases that they see a lot but that can be managed better.
Also, the duo holds monthly telementoring seminars with all the stewardship teams and any providers or staff members at the participating hospitals who wish to attend.
“We have a didactic session about an important stewardship topic, and then we have the stewardship teams share their data. Then, we discuss cases, projects, and [tactics] that work in each facility,” Vento explains. “We moderate that discussion so that there is shared learning.”
Typically, the topics for these monthly seminars revolve around an infection that is seen commonly in the hospitals and affects many patients or an infection associated with bad outcomes if it is not treated appropriately, Veillette explains.
UTIs affect many patients and have been a frequent topic of discussion at the monthly seminars. The stewardship teams discuss which patients require treatment, what antibiotics to use, and what the duration of treatment should be. “We are going around to each site talking about our new local guidelines for UTI management,” Veillette says.
Alternatively, Veillette notes that S. aureus bacteremia is an infection that is associated with severe morbidity and mortality if not treated appropriately. This has been another topic at monthly seminars. “We have spent at least two sessions talking about how to interpret blood cultures and tests related to that infection, and what is the optimal way to treat it,” he says.
For small hospitals still struggling to comply with the regulatory requirements for antibiotic stewardship, Veillette suggests they evaluate what resources might be available to them in the community. Consider partnering with a local or state health department, a university, or academic medical center.
“There are lots of different forms of outreach that could be done. I think there is value in seeking out people who have experience with stewardship programs, infectious disease, and improving outcomes in this area,” Veillette explains.
Vento advises hospitals to consider what resources they have to put toward the effort, and what pieces they are missing. Some hospitals will even hire other people to handle stewardship for them, he observes.
“We personally feel like the [local] ownership piece is important because the responsibility of looking at your own issues and your own stewardship practices is really on the hospital,” he offers.
The way Vento sees it, antibiotic stewardship is no different than any other quality process in the hospital. “You want to own that process,” he says.
Further, Vento notes that hospitals that have taken the time to designate champions and identify the things they want to work on can seek help more easily from experts at a larger medical center or healthcare network to provide the specific assistance they need for their program.