IPs valuable partners in drug stewardship
Preserving drug efficacy, saving big bucks
With the misuse and overuse of antibiotics driving drug resistance in general and emerging Clostridium difficile in particular, infection preventionists and health care epidemiologists want to have a greater role in antimicrobial stewardship programs.
A wide variety of multidrug resistant organisms (MDROs) have emerged under selective pressure of massive antibiotic misuse — a lot of it in the outpatient setting — with the very real threat of a "post-antibiotic" era underscored time and again. More recently, C. diff has driven discussions of reining in drug use, as antibiotic therapy can clear a niche for the now widespread virulent NAP1 strain of the spore-forming bacillus to set up in the patient's gut.
What can infection preventionists and health care epidemiologists bring to the table? Plenty, says the Association for Professionals in Infection Control and Epidemiology (APIC) and the Society for Healthcare Epidemiology of America (SHEA). In a joint position paper they emphasize that they are the professional organizations with the historical focus, expertise and credibility in articulating and implementing best practices in antimicrobial stewardship and infection prevention and control.1
Specific contributions they can make to multidisciplinary drug stewardship programs include:
— Identification of MDROs detected among the population served by a health care facility
— As part of surveillance, the monitoring and reporting of trends over time involving MDROs
— Oversight of the use of standard and transmission-based precautions aimed at preventing cross transmission of pathogens
— Compliance with hand hygiene
— Use of surveillance data to inform risk assessment and planning for prevention of infection
— Education of clinicians on prudent and appropriate use of antibiotics
— Development of clinical algorithms for treating infections
— Audit, analysis and reporting of data on HAIs
— Implementation of strategies aimed at prevention of infection and elements involving prescribing and therapeutic use of antimicrobials, (e.g., guidelines, decision support involving order/entry, de-escalation)
"It is a priority — a call to action, " says Michelle Farber, RN, CIC, president of APIC. "Antibiotic stewardship is a new skill that we aim to teach our professionals. We are trying to make a difference."
An obvious benefit to such programs would be IP reports on a given facility's current level of multidrug resistant organisms and patterns of drug susceptibility.
"Our responsibility with antibiotic stewardship includes educating our physicians about the burden of antibiotic resistance within our organization — breaking it down and making it actionable data for your clinicians," Farber says. "We're in those charts and we are seeing those providers that are using inappropriate antibiotics — so just sharing that information. A lot of stewardship programs are encouraging the IP's role . We don't order antibiotics but we can share this information — the connection between the antibiotic usage and C. diff for example."
The APIC-SHEA position paper comes at a time when few new antibiotics are in development, making careful use of the remaining drugs critical. Antimicrobial stewardship programs can effectively identify targeted organisms, prescribe the most appropriate empiric antibiotic, and institute precautions to prevent spread. Once susceptibility is known, treatment can be narrowed to the most precise choice.
"Infection preventionists and healthcare epidemiologists play a pivotal role in this approach by assisting with prompt detection of MDROs and promoting compliance with standard and transmission-based precautions," says lead author Julia Moody, MS, SM(ASCP), of HCA, Inc.
Among the practical approaches to this complex problem is just to take an antibiotic "time out," advised Cliff McDonald, MD, chief of the prevention and response branch in the Division of Healthcare Quality Promotion at the Centers for Disease Control and Prevention.
"Reassess after a patient has been on antibiotics for a day or two — do they still need those antibiotics?" he says. "Order the appropriate cultures before the antibiotics are started, and whenever possible, stop antibiotics that are no longer needed."
A costly decision
In addition to preventing rising resistance and C. diff infections, clamping down on antibiotics speaks to the bottom line. According to a recently published study, which evaluated a seven-year antimicrobial stewardship program at University of Maryland Medical Center (UMMC), the program eliminated $3 million from the hospital's annual budget for antimicrobials by its third year.2
After seven years, it had cut antibiotic spending per-patient day nearly in half. Cost savings were evident across hospital departments, including the cancer center, trauma center, surgical and medical intensive care units and transplant service. Importantly, these savings did not compromise quality of patient care. The study found no increases in mortality, length of stay, or readmission to the hospital.
Despite its success, however, the program was terminated in 2008 in favor of providing more infectious diseases consults. The consequences of that decision were immediate. Antimicrobial costs increased by 32% — nearly $2 million — within two years after the program was terminated according to the research.
"Our results clearly show that an antimicrobial stewardship program like the one at UMMC is safe, effective, and makes good financial sense," says Harold Standiford, MD, medical director for antimicrobial effectiveness at UMMC and the study's lead author.
The central component of the UMMC program was an antimicrobial monitoring team (AMT) that included an infectious diseases physician and a clinical pharmacist with infectious diseases training. The AMT made daily rounds and provided real time monitoring of antimicrobial use with active intervention and education when changes in treatment were recommended. The team also provided leadership in discussions about changes to antibiotics on the formulary and the development of relative policies and guidelines.
When the program was terminated, the AMT was disbanded in favor of additional personnel who provided infectious diseases consults throughout the hospital including in areas caring for highly specialized patients. It was believed that these additional personnel, though decentralized, would provide appropriate stewardship and render the AMT redundant. That decision proved costly, however, and in light of the study's findings the medical center has restarted a modified stewardship program including an AMT.
"Investing in stewardship not only helps preserve our dwindling antibiotics, it can also help to eliminate wasteful healthcare spending," Standiford says. "We believe this is an important lesson to keep in mind when considering the allocation of resources to stewardship programs."
- Moody J, Cosgrove SE, Olmsted R, et al. Antimicrobial stewardship: A collaborative partnership between infection preventionists and healthcare epidemiologists. AJIC 2012; 40: 94-95
- Standiford HC, Chan S, Tripoli M, et al. Antimicrobial Stewardship at a Large Tertiary Care Academic Medical Center: Cost Analysis Before, During, and After a 7-Year Program ICHE 2012; 33:4 (Special Topic Issue: Antimicrobial Stewardship, April 2012).