CDC to track hospital antibiotic use with new electronic NHSN module
APIC, SHEA issuing joint paper on IP role
By Gary Evans, Executive Editor
Trying to rein in the widespread misuse of antibiotics that is driving the rise of pan-resistant infections, the Centers for Disease Control and Prevention has created an electronic tracking system that will allow hospitals to monitor and benchmark drug use much as they already do for health care associated infections (HAIs).
The landmark initiative is one of several high priority national efforts to stop the misuse and overuse of antibiotics, which are contributing to a rising tide of multidrug resistant organisms (MDROs). The new CDC surveillance component comes with the tacit concession that data on antibiotic use — and certainly misuse — has been something of a blind spot in the public health system. The CDC is essentially applying a time-honored adage of infection prevention: "To measure is to control."
"Historically, it's been difficult to get information on exactly what antibiotics are being used in the various hospital locations," says Arjun Srinivasan, MD, a medical epidemiologist in the CDC's Division of Healthcare Quality Promotion. "A lot of people have pointed out that if you can't monitor it — measure it — then you don't know if you're doing well or where you could do better."
The creation of an accurate data base of antibiotic use should provide a much more detailed view of a growing national problem.
"When you look at the studies on antibiotic use it's quite clear that a substantial percentage of the antibiotics that we use in hospitals are used unnecessarily," Srinivasan says. "They are being given to patients who don't have infections at all, or they are being given for too long, or two antibiotics are being given when one would be sufficient. There is a great deal of improvement that we can make to reduce antibiotic use."
Antibiotic misuse can select out resistant organisms, undermine effective treatment, cause side effects, and set up patients for HAIs like Clostridium difficile infection. In addition, the CDC effort has a real sense of urgency due to increasing reports of gram negative infections that are becoming resistant to the full formulary.
"Hospitals around the country are seeing more patients with these gram negative infections, which are in some cases essentially untreatable," says Steve Solomon, MD, director of antimicrobial resistance in the CDC's Division of Healthcare Quality Promotion. "They are having to use not just second-line, but-third line therapies like colistin."
Such drugs are problematic due to possible adverse effects and other clinical issues, but may be the last resort against gram negative pathogens like multidrug resistant strains of Klebsiella pneumoniae and Acinetobacter baumannii. With treatment so limited, no new drugs forthcoming, decolonization virtually impossible, and mortality rates reported in the 40% range, antibiotic stewardship and rigorous infection control measures are the two and only options. Add to all that the capability of these gram negative bugs to transfer full resistance between species via plasmids, and the severity of the situation is apparent.
"The threat of untreatable infections is real," Srinivasan says.
Pilot program begins with eye to expand
The new antibiotic tracking module is part of CDC's National Healthcare Safety Network (NHSN), which is currently monitoring infections in some 4,800 hospitals. The ambitious initiative will eventually include reporting information on MDROs, but the immediate focus is antibiotic stewardship.
"We are now in the process of working on a companion module for NHSN that will allow facilities to electronically track antimicrobial resistance," Srinivasan says. "Within the next couple of years, we will have both the [drug] use and the resistance pieces built into the NHSN. We are beginning with the use portion."
The CDC is piloting the program in some 70 hospitals in three states, he adds. "We were able to get some funding to support a collaboration with three state health departments and one city health department," he says. "We hope that in short order we will begin receiving information from these pilot hospitals and we can then expand from there. "
In addition, any hospital that participates in the NHSN can access the system by working directly with its pharmacy software vendor to transmit data electronically from drug administration or barcoding records, the CDC advises. (See editor's note, below).
"This is a very future-looking module because it uses entirely electronic data for the reports," he says. "The data comes directly from the hospital's medication-use system into the NHSN module, so there is no data entry that is required by a healthcare facility. "
The CDC is also working with pharmacy software companies to get the system incorporated in their updated products. "It will [eventually] be part of the system," Srinivasan says. "You could basically activate that function and then your antibiotic use data will be sent directly into the NSHN. Then you as a facility can use it — it will be reported out to the various hospital locations so you can monitor your own use. We are hoping to get enough facilities participating so we can begin to report information that will allow facilities to compare themselves to similar facilities — to understand if they are above or below average with respect to antibiotic use."
Hospitals will be able to assess their antibiotic use against similar facilities and by type of unit, he says. "For example, if you are a medium size hospital in a particular location and you have one intensive care unit, roughly how much antibiotics would be used by a similar facility in a given location like a medical ward or a surgical ward?" he says. "This is much like we have done for HAIs with CLABSI rates."
As with HAIs, facilities can draw their own conclusions about their data if, for example, an outbreak spurs heavy antibiotic administration in a given unit.
"The information would be used exactly like hospitals are accustomed to using their infection rates or standardized infection ratios," he says. "A hospital may have a higher than expected infection rate but it may be that there is a very good explanation for that — very sick patients, an outbreak. This helps point you in directions to say [for example] we need to look at our antibiotic use on this particular unit because it's higher than what we have expected. Or let's go look at this unit because their use is much lower than we expected. Are they doing something we need to emulate in other [departments]?"
Defining the IP role
Though preventing patient-to-patient transmission of MDROs is a given for infection preventionists, their role in the larger context of antibiotic stewardship has been less clearly defined. That is clearly in flux, though public health officials are cognizant of the multiple duties IPs are already performing.
"We think infection preventionists can play an important role in antibiotic stewardship, but it's an area where we have some work to do," Srinivasan says. "There are definitely roles for IPs, but we have to be obviously sensitive to the fact that they are already stretched beyond their limits. We need to find ways to harness the power of what they are already doing — to dual purpose it for both infection prevention and for antibiotic stewardship."
In that regard, the CDC has been working with the Association of Professionals in Infection Control and Epidemiology (APIC), which was preparing to issue a position paper on IPs and antibiotic stewardship as this issue of Hospital Infection Control & Prevention went to press. APIC will issue the paper as a joint statement with the Society for Healthcare Epidemiology of America (SHEA), says Russ Olmsted, MPH, CIC, APIC president and an infection preventionist at St. Joseph Mercy Health System in Ann Arbor, MI.
"Part of the purpose of this paper is to outline some of the key things I think a lot of IPs have been doing a for quite some time," he says. "This kind of crystalizes the notion that their work really does inform the antibiotic stewardship program. There is sensitivity about this issue. We don't want to promote a program that is going to add tasks on to [the IP], but this is really just recognizing that the IP is part of the stewardship program."
Indeed, there are already Joint Commission patient safety goals to reduce MDROs and the Centers for Medicare and Medicaid services is very interested in assessing antibiotic resistance issues as part of its hospital oversight and inspection activities. Many hospitals already have antibiotic stewardship committees, and IPs can be critical contributors by sharing the data they gather to prevent HAIs.
"We are not necessarily advocating that IPs go out and do something like medication utilization review in real time," Olmsted says. "But in the daily work we already do we are obviously focused on certain organisms. That data can be used in a couple of ways to help inform the stewardship program whether they are hitting the right target. It's also kind of a metric for assessing the impact of the infection program."
The link between antibiotic use and infection control is strikingly direct with C. diff, which has spread widely in hospital outbreaks involving a particularly virulent strain. Transmission occurs primarily in health care facilities, where exposure to antimicrobial drugs sets up the gut for onset of disease, triggering diarrhea that leads to a contaminated patient environment by the spore-forming anaerobic bacillus. Prior administration of fluoroquinolones in particular seems to trigger the appearance of cases, but a 2008 APIC C. diff survey found that only about half of responding hospitals had antibiotic stewardship programs in place.
Olmsted and colleagues at his facility were able to substantially reduce C. diff infections by focusing on antibiotic use. "We can't prove cause and effect but it looks like it was related to better use of antibiotics," he says. "We lessened use of some of these classes of antibiotics and saw a very significant [C. diff] drop."
Similarly, IPs can help connect the dots between other problem HAIs and antibiotic use patterns.
"The infection preventionists bring that rich surveillance data to that table," Olmsted says. "It's useful to see if there are trends or changes with the reduction of a certain class of antibiotics. The other thing we do is prevent the movement of the MDROs through good standard or transmission-based precautions. That also supports stewardship."
[Editor's note: To access a list of pharmacy software vendors who are working with CDC's new antibiotic use tracking system, see the Society for Infectious Disease Pharmacists website at www.sidp.org]