Inpatient antibiotic stewardship programs (ASPs) lower rates of healthcare-associated infections, increase microbial susceptibility to antibiotics, and save healthcare costs, according to ten case studies published in an Apr 26 report from the Pew Charitable Trusts (PCT).
"All antibiotic use contributes to the proliferation of antibiotic-resistant bacteria, and more than 2 million people are infected with antibiotic-resistant organisms each year in the United States, resulting in more than 23,000 deaths," the 63-page report says. The US Centers for Disease Control and Prevention (CDC) released a report in 2013 estimating that about half of antibiotics prescribed each year are unnecessary.
ASPs curb inappropriate antibiotic prescriptions with clinician education, better matching of antibiotics to infections (bug-drug matches), and rigorous authorization protocols for prescriptions, yet often are met with some resistance due to funding insufficiency, lack of dedicated staff or laboratory capability, and changes in accepted standards of care.
PCT's report, "A Path to Better Antibiotic Stewardship in Inpatient Settings," describes ASPs in five community hospitals, three academic hospitals, and two long-term care facilities. Each had incorporated all seven of the CDC's "Core Elements of Hospital Antibiotic Stewardship": leadership commitment, accountability, drug expertise, action (eg, systems to monitor treatment and bug-drug matches), education, tracking, and reporting.
All except an academic hospital with a 20-year history of antibiotic stewardship interventions implemented their programs between 2006 and 2011. Though all demonstrated significant leadership and commitment to the interventions, each facility used practices and technology specific to their patient populations, outbreak history, staff availability, and lab capacity.
Administrative and physician support for stewardship
Outbreaks and high rates of healthcare-associated infections spurred operational support and funding for ASPs in four facilities, according to the report. Vibra Hospital of Northern California in Redding, Calif., and Sharp Villa Coronado Long-Term Care Facility in Coronado, Calif., were able to obtain support for nascent ASPs after linking antibiotic use to increases in healthcare-associated Clostridium difficile (C diff) infections.
Park Manor Nursing Home in Park Falls, Wis., and St. Tammany Parish Hospital in Covington, La., instituted their protocols after an outbreak of methicillin-resistant Staphylococcus aureus (MRSA) and an increase in infections after coronary artery bypass grafts, respectively.
Blessing Hospital in Quincy, Ill., received institutional approval for an ASP after demonstrating the need for stewardship with a 4-month study on inappropriate use of aztreonam, tigecycline, daptomycin, and linezolid.
Staff roles and laboratory capacity
Most ASPs were led by at least one infectious disease or family practice physician and pharmacist who dedicated several hours per week to monitoring prescriptions and effectiveness of antibiotic treatment, the report explains. Exceptions were the program at Sharp Villa Coronado Long-Term Care Facility, which was led by pharmacists and pharmacy students, and the nurse-led ASP at Park Manor Nursing Home.
Because Park Manor had neither an on-site physician nor a pharmacist, nurses maintained detailed reports of patient infections, bacterial culture results, and antibiotic use, and then developed scripts to communicate patient status and care to physicians. The use of nursing staff to shepherd stewardship efforts, carry out active surveillance for urinary and respiratory tract infections, and communicate between patients and doctors reduced the number of unnecessary prescriptions, the authors said.
Both long-term care facilities were able to perform simple lab tests but had to send samples off-site for more complex testing and culturing. Several community hospitals lacked the ability to conduct on-site and/or rapid diagnostic testing and culturing, which increased waiting time for decisions about antibiotic therapy.
Lowering antibiotic use and infections
Ongoing treatment monitoring and patient interventions had the most measurable effects on inappropriate antibiotic use, the report states. Vibra Hospital found that changes to antibiotic regimens were needed in all 93 patient cases it monitored from May to June 2015. Vibra clinicians worked with the ASP to schedule antibiotic treatment stop dates for 46 patients, discontinue treatment for 42, review cultures and assign new prescriptions in 10 cases, and change four dosages because of new information on weight or kidney function.
Sharp Villa's implementation of an antibiotic dosing protocol to prevent renal toxicity and ongoing therapy assessment lowered antibiotic use by 59%, with significant decreases in broad-spectrum antibiotics, vancomycin, antifungals, and C diff therapies. From 2011 to 2015, Escherichia coli susceptibility to levofloxacin at Sharp Villa rose from 24% to 54%.
Several facilities saw decreases in healthcare-associated C diff rates after ASP implementation. After educating physicians on substitutes for restricted or nonformulary antibiotics and transitions from intravenous to oral therapy, Williamson Medical Center in Franklin, Tenn., observed C diff rates fall from 26.3 infections per 10,000 patient-days in 2013 to 21.1 cases per 10,000 patient-days in 2014. At the same facility, the susceptibility of Pseudomonas aeruginosa to levofloxacin increased from 58% in 2009 to 79% in 2014.
St. Tammany's antibiotic treatment surveillance and training interventions led to a fall in C diff rates from 9.6 per 10,000 patient-days in 2013 to 6.4 in 2014. Through active surveillance and close physician-pharmacist partnerships, the hospital was also able to reduce daily doses of daptomycin by 84%, linezolid by 79% tigecycline by 86%, and micafungin by 61%, and lowered total antimicrobial costs from $25.93 to $8.32 per patient-day.
The University of California, Davis Medical Center's focus on prescription audits, bug-drug mismatches confirmed by culture, yeast colonization of sterile sites, and vancomycin resistance yielded a 23% reduction in C diff rates, which saved an estimated $23,540 in costs. Prescription decreases for 11 antibiotics targeted for intervention by the facility’s ASP led to cost savings of about $119,009 since the program began in 2011.
Opportunities and challenges
In most cases, ASPs at the 10 facilities proved effective when procedures were automated and when continual communication about antibiotic therapy was maintained between clinicians, pharmacists, and lab staff, according to the report. For example, Strong Memorial Hospital in Rochester, N.Y., held weekly antibiotic stewardship rounds between ASP members and six clinical services. Three hospitals observed increasing clinician acceptance of pharmacists' prescribing recommendations over the course of their programs.
Barriers noted by some of the hospitals and centers included lack of dedicated staff time and funding for technology, including electronic health records in long-term care centers, that would more closely track patient therapies.
A recent action plan from the Obama administration proposed that all acute care hospitals and long-term care facilities implement ASPs, and California recently made it a requirement for acute care hospitals. Given the trend toward formalizing antibiotic stewardship and the benefits such programs can yield for patient care, microbial susceptibility, and facility costs, these case studies offer diverse methods and results to help burgeoning programs evaluate ASP feasibility in their institutions, the report says.
See also:
Apr 26 PCT report landing page and summary
Full text of PCT report
Mar 29 CDC guidance on nursing home antibiotic stewardship
May 7, 2015, CDC guidance on hospital antibiotic stewardship
