Groups aim to increase antimicrobial stewardship

Robert Roos

Mar 15, 2012 (CIDRAP News) – Infectious-disease specialty groups are teaming up to call for increased use of antimicrobial stewardship programs, saying such efforts can help preserve the effectiveness of anti-infective drugs while reducing medical costs.

As evidence, the groups pointed to a new study showing that the University of Maryland Medical Center (UMMC) in Baltimore saved up to $3 million a year by setting up an antimicrobial stewardship program involving a special team to monitor the use of the drugs.

The organizations—the Society for Healthcare Epidemiology of America (SHEA), the Infectious Diseases Society of America (IDSA), and the Pediatric Infectious Diseases Society (PIDS)—released a position paper calling for a number of steps to increase such stewardship programs.

For example, they advocate including antimicrobial stewardship in curricula for healthcare professionals and collecting data on resistance in both hospitals and outpatient clinics.

Meanwhile, Margaret Chan, director-general of the World Health Organization (WHO), warned in a speech yesterday of the threat of a "post-antibiotic era." Speaking at a European conference on antimicrobial resistance, Chan praised the European Union's efforts to preserve antibiotics but said the global challenge is daunting.

Antimicrobial stewardship programs are not new, as SHEA and IDSA released recommendations about them in 1997 and again in 2007, said Ruth Lynfield, MD, chair of the IDSA's National and Global Public Health Subcommittee. But the groups are working for wider use of such strategies, especially in smaller hospitals, she said.

Maryland study
In 2001 UMMC set up an antimicrobial stewardship program that centered on an antimicrobial monitoring team (AMT), according to a report in the April issue of Infection Control and Hospital Epidemiology, a special edition dedicated to antimicrobial stewardship.

The team consisted mainly of an infectious-diseases physician who worked half-time on the program and an infectious-diseases pharmacist with an 80% time commitment. The team provided "real-time monitoring of antimicrobial orders and active intervention and education when necessary," the report says.

The team tried to identify ineffective or excessive antimicrobial coverage, ensure that drug orders complied with policies, identify patients whose treatment could be safety switched from parenteral to oral routes, and suggest infectious disease consultations for difficult cases, the report explains. They were aided by a computer decision-support system.

The authors determined that the program paid off handsomely. Antimicrobial costs per 1,000 patient-days decreased from $44,181 at baseline in 2001 to $23,933 by the end of the program in FY 2008, a 45.8% drop, they write. "There was a reduction of approximately $3 million [per year] within the first 3 years, much of which was a decrease in the use of antifungal agents in the cancer center." But there were significant savings in the use of other types of antimicrobials as well.

"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," SHEA officials said in a press release about the study.

Despite its success, the program was dropped at the end of FY 2008, in part because of some dissatisfaction over a preauthorization requirement for the use of certain drugs, the article says. The program's funding was then used to provide for additional infectious-diseases consultation throughout the center, on the assumption that this would ensure good antimicrobial stewardship.

However, UMMC's antimicrobial costs rebounded after this change, rising from $23,933 to $31,653 per 1,000 patient-days in 2 years, a 32.3% increase that added up to $2 million, the report says. The authors allow that certain external factors, such as higher recommended dosing for vancomycin, may have contributed to this increase.

Since stopping the program turned out to be costly, the report says, UMMC has since restarted it, but with one difference: an automatic infectious diseases consult has replaced the preauthorization requirement for use of restricted antimicrobials.

"Our research shows that investing in stewardship not only helps preserve our dwindling antibiotic tools, it can also help to eliminate wasteful healthcare spending," Harold C. Standiford, MD, first author of the report, commented in the press release.

Recommended initiatives
The new position paper from SHEA, IDSA, and PIDS gives recommendations for the "mandatory implementation" of antimicrobial stewardship in all healthcare arenas. It also suggests ways to monitor such programs and addresses deficiencies in education and research in the field as well as the lack of accurate data on antimicrobial use in the United States.

The paper calls for the following national stewardship initiatives:

Including antimicrobial resistance and stewardship in the curriculum for healthcare professionals
Collecting data on antimicrobial use in both inpatient and outpatient settings, since they are critical for monitoring antibiotic use and its relationship to antibiotic resistance
Monitoring stewardship initiatives in ambulatory and outpatient healthcare settings, with a suggestion that federal agencies fund pilot projects to develop programs in these settings, including expanded use of electronic health records
Using regulatory approaches to require health settings to launch stewardship programs, such as having the Centers for Medicare and Medicaid Services (CMS) require participating institutions to develop programs
Filling the knowledge gaps in our understanding of antibiotic resistance, especially the transmission of resistance

Programs more common in large hospitals
Lynfield, who is Minnesota's state epidemiologist, said she is unsure what proportion of hospitals nationwide have antimicrobial stewardship programs, but a recent Minnesota survey indicated they are less common in smaller hospitals.

In December the Minnesota Department of Health (MDH) conducted an informal online survey of all acute-care hospitals in the state, including 79 "critical access" hospitals (generally those with 25 or fewer beds) and 53 larger facilities, Lynfield said.

Of 37 smaller hospitals that responded, 10, or 27%, had an antimicrobial stewardship program. For the larger ones, 18 of the 28 respondents, or 64%, had such a program, she said.

"I think academic and tertiary-care facilities are developing programs or they have programs in place," Lynfield said. "SHEA and IDSA came out with recommendations about antimicrobial resistance and stewardship in acute care in 1997 and again in 2007, so these are issues that have been discussed now for a number of years."

"It's really important that community hospitals also have antimicrobial stewardship programs," and a number of people and groups have been working to promote that, she added.

"In a community hospital it' a little more challenging, because they may not have an infectious disease physician, let alone a pharmacist who has expertise in infectious disease issues," Lynfield said. But "it absolutely can be done," she added.

She said the MDH is working on best practices and a tool kit to help Minnesota healthcare facilities launch such programs, starting with acute-care facilities and going on to long-term care and ambulatory care.

Chan's warnings
WHO Director-General Chan, in her European speech yesterday, warned that the world may be heading not for a return to the "pre-antibiotic era," as some experts suggest, but to a "post-antibiotic era."

"A post-antibiotic era means, in effect, an end to modern medicine as we know it. Things as common as strep throat or a child's scratched knee could once again kill," she said in prepared remarks.

Chan praised the efforts of the EU, and especially Denmark, to track and counter antimicrobial resistance. But she warned that circumstances and practices in developing countries create very tough challenges.

"Many countries are crippled by lack of capacity, including laboratory, diagnostic, quality assurance, regulatory, and surveillance capacity, and control over how antimicrobials are obtained and used," she said.

"For example, anti-malaria pills are sold individually at the local marketplace. Counterfeit and substandard antibiotics abound. In many countries, the pharmaceutical industry is the principal source of prescribing information for doctors."

She added that the WHO is aware of the challenges and is addressing them through various initiatives.