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Antimicrobial stewardship program for the budget-conscious hospital
Launch some or all of these changes
All hospitals need to form some sort of antimicrobial stewardship program (ASP), and lack of funding should not be a deterrent, experts say.
There are some very effective, inexpensive ways hospitals can make a big difference in reducing antibiotic resistance and hospital-acquired infections.
For instance, one low-hanging fruit is to start a campaign to switch patients from intravenous to oral antibiotics, says Keith Kaye, MD, MPH, professor of medicine and corporate director of infection prevention and antimicrobial stewardship at Detroit Medical Center and Wayne State University in Detroit, MI.
Plus, an intravenous-to-oral antimicrobial conversion program could save a hospital thousands of dollars in antibiotic costs, and it would improve patient care.
Kaye and other experts offer these suggestions for what to include in an antimicrobial stewardship program that is created on a tight budget:
Train pharmacists and others in infectious diseases: When a hospital is unable to hire an infectious disease (ID) pharmacist, it can at least provide some ID training for pharmacists.
Each hospital needs to form an antimicrobial committee that contains a physician leader and a pharmacist leader. So ID training is essential for these individuals.
Hospital pharmacists can educate themselves by reading ID textbooks and journals. They also can attend ID conferences and workshops, take webinars, such as those found on the website of the American Society of Health-System Pharmacists (ASHP), and they can take courses on the subject.
And they can shadow microbiologists and infectious disease physicians, suggests Robert P. Rapp, PharmD, FCCP, professor of pharmacy and surgery emeritus at the University of Kentucky Medical Center in Lexington, KY.
Invest in an infectious disease (ID) physician: ID physicians might not be available to every hospital, but when a hospital has access to an ID doctor, it should pay him or her for time spent on an antimicrobial stewardship committee, Rapp suggests.
"If you don't have an ID physician, find an internist who's interested," he adds. "A hospital with 300-400 beds should pick up 50% of the physician's salary for this program."
The core antimicrobial stewardship team should include an infectious disease doctor, but it's not essential, Kaye notes.
"There should be someone who receives some compensation or support for their activities because this brings them into the fold much more aggressively," Kaye says.
Collect data to share with ASP team and hospital leadership: Before starting an antimicrobial stewardship program, a hospital pharmacy director could collect data that will demonstrate the seriousness of the hospital's drug-resistance problem.
A first step is to analyze the antibiogram from the hospital's clinical microbiology laboratory. This is a summary, usually published yearly, by Microbiology that summarizes antimicrobial susceptibility. Based on these results, hospital ASPs can target specific projects to reduce the drug-resistance rates of these particular strains and gear antibiotic use to optimize defeating them.
The hospital's microbiologist or lab director can explain the antibiogram data, and they can help others interpret the information, says Steve Cano, RPh, MS, senior director of the pharmacy and chief pharmacy officer at Cambridge Health Alliance in Somerville, MA.
"What we do typically is have a working relationship with the pharmacy and ID physicians and the lab to sit down annually and review the latest information on the antibiogram, comparing it to previous years," Cano explains. "Our microbiologists tell us what the trends look like to them, and we digest this information and use it when updating recommendations for antibiotic use."
The ASHP website has a webinar with Kaye that explains how to evaluate an antibiogram, Rapp says.
A next step is to monitor antibiotic prescribing on a per-provider basis and then to provide feedback to providers about what they're doing differently than what is recommended in the latest guidelines and literature, Rapp says.
"You can give them feedback in writing on a chart or have a one-on-one conference with them," he says. "So the next time the physician runs into that situation, hopefully, he won't repeat that mistake."
"We collect lots of data on the costs associated with antibiotic use," Cano says. "That's the easiest thing to wrap your arms around, and it's a surrogate measure of how you're doing with antimicrobial management."
Pharmacy directors should collect data on which products consume most of the expenditures and overall antimicrobial purchases.
"Do these expenses look appropriate or not?" Cano says. "You can see whether the antibiotics of choice are being used most often or if there are other antibiotics being used that aren't indicated."
Learn techniques for maximizing antibiotic potency without waste: The goal is for a pharmacist leader to become an expert in antimicrobial use and pharmacodynamics, Rapp says.
"We want to get people to give drugs in the way they kill bacteria best," he says.
For example, a pharmacist leading an ASP could initiate an educational program that teaches physicians about the latest literature on providing continuous or extended infusions of beta-lactam antibiotics, which can enhance dramatically the killing of bacteria, Rapp explains.
"Instead of giving an infusion of 1 g over 30 minutes, which gives you a huge peak but quickly falls off, you might need to have 1 g over 4 hours every 8 hours for antibiotics like penicillin," he says. "When you kill the bacteria quicker, they don't mutate and develop resistance as efficiently."
Develop a strategic plan: Develop an ASP that is consistent with an organization's vision and values, and form a team to carry out this ASP, Cano says.
"When you're doing planning at the team level, make sure your plans sync up with larger objectives, and make sure you have an opportunity to get your voice heard when the larger strategic planning process is being developed," Cano says.
Each planned objective needs a written action plan that will hold the team and organization responsible for reaching the desired outcomes. These action plans will need to be followed-up with documentation of progress.
The organization will need an antimicrobial stewardship team to carry out the plan and activities.
The antimicrobial stewardship committee ideally will include an ID pharmacist, the ID physician, and someone who is good with managing data reports, Kaye says.
"This is not necessarily someone with clinical knowledge, but it's someone who knows how to extract information from the hospital's database," he adds.
Target high-outcomes, low-resource projects first: Besides switching IV medication to oral antibiotics, another good initial project to implement involves improving how blood cultures are obtained, Kaye says.
"Also, if you have an intensive care unit (ICU) team that's interested or that has strong leadership, you could focus on shortening the durations of therapy around pneumonia treatment," he says.
"Choose things that might be manageable and that you can control with focused efforts from the pharmacy's point of view or that has a particular disease state where there's strong, interested leadership," he adds.
For example, at Cambridge Health Alliance, there is a project that will result in more protocols that allow clinical pharmacists to manage antimicrobial therapy, Cano says.
"Pharmacists more and more are being asked to dose drugs, minimize toxicity, change dosing, and we'll put protocols in place for this," he says.
The project will include seeking the ASP committee's review and expertise, piloting the protocols, and determining which measurements to collect, he adds.
Another good project to start involves surgical site infection prophylaxis, Kaye says.
"People get antibiotics before surgery and have to be given these usually an hour before the surgical incision," Kaye says. "The guidelines recommend you stop antibiotics 24 hours after surgery, but some are continued for long periods of time after surgery."
A project targeting this issue would include writing a protocol that limits antibiotic use for 24 hours after surgery. It also would include staff education about research showing that extending antibiotic use past 24 hours does not provide any added protection to patients and makes them more at risk for antibiotic side effects such as diarrhea caused by Clostridium difficile, Kaye suggests.
"In your first year with an antimicrobial stewardship program, you will want to evaluate and improve your antibiotic prescribing specifically around Clostridium difficile risk," Kaye says. "The two major risk factors for C. difficile are being in the hospital and getting an antibiotic."
For instance, hospitals often use fluoroquinolones inappropriately, and this drug is associated with C. difficile, he adds.
Another good first-year ASP project is to develop an algorithm for shortening the treatment of ventilator-associated pneumonia (VAP) from several weeks to 7-8 days, Kaye says.
"Having an algorithm makes the treatment more concrete and organized," he says.
Whichever projects a hospital decides to tackle, the best strategy is to select projects that fit in with the organization's needs and goals, and which are feasible from a resource perspective.
"Think about what a major attainable goal might be for the first year," Kaye says.