Antibiotic stewardship programs curb resistance

Using PharmDs and data to quell HAIs

Which came first: the chicken or the egg? Likewise, are what the Centers for Medicare & Medicaid Services labels "never events" really never events if they happen? The philosophical ramblings on this are endless, and whether these events are eradicable, it's become a reality this month that if a patient acquires an infection in your hospital, your hospital will be footing the bill. And whether or not you can eliminate infections, it is incumbent now that you find effective and cost-appropriate ways of dealing with them.

Data tracking measures, mandatory reporting requirements, and no-pay rules for hospital-acquired infections (HAIs) put the issue front and center this month, and in the absence of what many see as clear guidelines on prevention, it is every hospital for itself in determining best practices to deal with HAIs, and to do it cost-effectively.

Antimicrobial stewardship programs are one of the hot trends, and VHA Inc. and Premier Inc. have rolled out measures to help hospitals manage their own infection patterns. According to health care attorney and blog author David Harlow, hospitals involved in programs such as these "are on the cutting edge, and anyone who's not involved in a program like that through a purchasing association or otherwise is going to have do that soon because they're going to have to address every way of reducing hospital-acquired infections."

What he refers to as once "fringe behavior" — that is, the move to avoid overuse of antibiotics — is going to become much more crucial. And that is what these programs are banking on.

An article in the Feb. 14 issue of the Journal of Antimicrobial Chemotherapy, reads: "Antibiotic use is widely accepted as being responsible for the selection and maintenance of antibiotic resistance. It is less obvious, however, that it is also responsible for increasing transmissibility and pathogenicity of many multiresistant bacteria and may actually be increasing the number of hospital-acquired infections. Antibiotic stewardship should be given much more emphasis in the fight against HAI."1

Robert Pickoff, MD, MMM, chief medical officer at Hunterdon Medical Center in Flemington, NJ, says the hospital was looking into how to address the sensitivity patterns of bacteria at the facility when VHA approached them about being a test site for its antibiotic stewardship "Bugs and Drugs" program.

As part of its participation, Pickoff worked with John Gums, PharmD, professor of pharmacy and medicine at the University of Florida, who helped create VHA's antimicrobial resistance database, which participants can use to review resistance patterns and to benchmark them regionally or nationally. "[Gums'] interest," Pickoff says, "was in taking hospital information, that is the pattern of antibiotic use and the antibiogram, which is the resistance and sensitivity patterns of the bacteria in the hospital, and analyzing the data to see what could be done to reverse the trend of rapidly increasing resistance."

In implementing the recommendations it received from Gums, Hunterdon brought on doctoral-level pharmacists affiliated with Rutgers' teaching faculty and Hunterdon's own pharmacy residency program to work in sync with the medical staff. Pickoff credits this interaction as being critical to the success the facility would have.

Each hospital must make its own priorities in stemming the tide of resistance, Pickoff says. Hunterdon chose Cipro as its first target and in studying its resistance patterns created guidelines for the drug's use as an empiric therapy. The outcome was an order form for physicians. When an antibiotic is ordered, the doctor has to indicate "whether it is empiric or therapeutic, what cultures were done, and what the results were," he says. The doctoral-level pharmacists then review the form and make suggestions as needed on the antibiotic chosen for treatment.

Pickoff says the test case examined two specific bacteria against Cipro. "We showed a sensitivity for two bacteria," he reports, "Klebsiella and Pseudomonas, and in one case, the sensitivity went up from 21% to 54% and in the other it went from 51% or so to 79%."

On the docket now is how these interventions might affect cost and even throughput. "We're looking now at the effect of appropriate antibiotic use on length of stay and cost per case. We think that by using antibiotics appropriately, we are going to be able to effect change," Pickoff says.

He reiterates the PharmD intervention in the success with the Cipro case. "That's the intervention that has made the difference" — that is, the back and forth communication and the educational aspect. "In addition to having these PharmDs making rounds in the intensive care unit with the intensivists on a daily basis, it's also interacting with the physicians and nurses and affecting change in the use of antibiotic therapy. The combination of those and the team approach is what we think is key to the success we've had in reversing the tide of resistance to Cipro."

Now, it's on to another antibiotic of choice for Hunterdon as it tries to replicate the success it had with its first case. But Pickoff says interventions can never be successful if they only happen in the hospital. Any strategy that's worth its weight must include the community, of which the hospital is only a part.

"One thing we've learned is that if you want to effect change inside the hospital," he says, "you really have to go outside of the walls of the hospital to influence what's being done in the community. Because if you get a patient in from the community already having resistant patterns... the hospital inherits those resistance patterns and it becomes a pattern of the hospital."

And it's not only the community at large, but in the primary care setting. When outpatient facilities in the primary care network involved with the hospital use electronic prescription writing, Pickoff says, they're also able to interact with the PharmDs "just as much as the inpatient physician does in terms of the advice for antibiotic choices and taking advantage of that advice."


  1. Gould, IM. Antibiotic policies to control hospital-acquired infection, J Antimicrob Chemother February 2008. doi:10.1093/jac/dkn039.