Antibiotic stewardship programs: 4 case studies

Approximately 23,000 deaths and at least 2 million illnesses occur annually in the United States due to drug-resistant bacteria, according to the CDC.

All antibiotic use has the potential to contribute to the development of antibiotic resistance. That's why it is key to reduce inappropriate antibiotic use in order to slow the growth of resistance.

Antibiotic stewardship programs (ASPs) in hospitals and other inpatient facilities help ensure that antibiotics are used only when they are needed, and that when they are needed, the most appropriate types, doses, and length of antibiotic treatments are used.

"ASPs have been shown to be effective in not only slowing the rise of resistant bacteria but also improving patient outcomes and safety by maximizing the effectiveness of antibiotic treatments and by reducing the adverse events associated with antibiotic use," says David Hyun, MD, senior officer, Antibiotic Resistance Project, The Pew Charitable Trusts. "ASPs help improve the quality and safety of patient care provided by hospitals while lowering total medical costs."

The Pew Charitable Trust recently released a report profiling how different healthcare facilities across the country are using antibiotic stewardship programs as part of their efforts to tackle the threat of antibiotic resistance.

"Each of the ASPs was able to create and implement effective stewardship programs tailored to the needs and resources of their facilities, demonstrating that there is no one-size-fits-all approach when it comes to antibiotic stewardship," Hyun says.

Here are four of the 10 ASP programs highlighted in the report that stand out for their diverse approaches.

Next: Four ASP approaches

#1. Vibra Hospital of Northern California, Redding, California

A rise in Clostridium difficile (C. difficile) infections, as well as multiple drug-resistant organism (MDRO) infections, spurred implementation of an ASP at this 56-bed long-term acute care (LTAC) hospital and 32-bed transitional care unit, according to the facility’s Infection Preventionist Debbie Wiechman, RN, CIC.

When the LTAC opened, the patient population consisted of medically complex patients who sometimes required antibiotic therapy.

"Approximately 90% of the patients admitted were already on antibiotic therapy and at times were taking three to four different antibiotics, most having no stop dates and sometimes having no cultures to help determine if the appropriate antibiotics were being used," says Wiechman.

She also observed that approximately 60% of the patients being admitted had MDROs, and that severe C. difficile was a growing problem.

The hospital’s infectious diseases physician (ID) convened a group of staff members to discuss the issue and the ASP was formed.

Once weekly, the four ASP program members-the ID, clinical pharmacist, hospitalist, and infection preventionist-meet after the pharmacy sends a list of the patients in the hospital who are taking antibiotics. Using electronic health records and some paper documentation, the ID then reviews patients with no antibiotic stop dates and those taking more than two antibiotics, high-cost antibiotics, unusual combinations, and fluoroquinolones (vancomycin, Levaquin, Cipro).

"Changes are made and a spreadsheet is completed noting all changes made," she explains. "Copies of the spreadsheet then go to the director of pharmacy for our corporate scorecard, to the case management team to assist in helping to plan the patients discharge, and to the wound team director."

Data are reported quarterly at pharmacy and therapeutics committee meeting.

"We saw a reduction of 60% in both C. difficile and MDROs in the first two years of our program," says Wiechman. "Seeing so much success it was determined that we had to make it a sustainable program, able to continue through changes in team members and training other staff to fill in when our core members were not available. We also felt it was important to adjust our days for meeting during holidays so that we wouldn't have any patients fall through the cracks."

Next: Pediatric partnership

#2. University of California Davis Medical Center, Sacramento, California.

For the past 20 years, the ASP at the health system primarily consisted of antibiotic restrictions and infectious disease authorization for use of restricted antibiotics, according to Hien H. Nguyen, MD, MAS, professor and vice chief of infectious diseases at the facility.  "We did this with the recognition that we should be judicious in our use of broad-spectrum antibiotics to avoid drug resistance."

However, over the last 10 years, the need to use a broad-spectrum of antibiotics for critically ill patients to ensure that they are started on appropriate therapy at the time of hospital admission has been increasingly recognized.

"These two concepts are essentially in direct opposition and we needed to find a way to reconcile this tension in antimicrobial prescription in the hospital," Nguyen says. "About three years ago we began in earnest to revise and improve our antimicrobial stewardship program."

The medical center partnered with its pediatric infectious diseases colleagues who had demonstrated that a program auditing the antimicrobial prescribing practices within the children’s hospital and providing feedback to prescribing physicians could greatly reduce overutilization of broad-spectrum antibiotics and reduce C. difficile infection rates.

"We found that we share many of the same issues in adult medicine in trying to improve antimicrobial utilization," Nguyen says. "So we modeled our adult program to create more of an audit/feedback mechanism targeting broad-spectrum and high risk antibiotics. We utilized our information technology systems to create more efficient work flows in reviewing antibiotic prescriptions. We also created electronic tools to document these interventions seamlessly within the daily work flow."

Nguyen says the approach requires great teamwork. Information systems track cultures closely and when antimicrobial susceptibility panels return showing that a patient is not on an active antibiotic, the stewardship team is alerted by the system and helps the care team adjusts and start the right drug. "Additionally, we want to optimize the dose based on a patient’s unique characteristics such as their renal function, drug-drug interactions, and other aspects of tailored prescriptions," says Nguyen.

Nguyen and his team have been able to show a decrease in the use of the top 16 broad-spectrum and high-risk antibiotics. "We’ve seen decreased rates of C. difficile infection likely due to antimicrobial stewardship program interventions and enhanced infection control measures," he says. 

From a managed care perspective antimicrobial stewardship is a program that potentially fulfills the Institute for Healthcare Improvement’s Triple Aim: improved quality, improved cost, and improved patient outcomes, according to Nguyen.

"Additionally, this can be a significant physician satisfier as well," he says. "Physician teams can be quite busy day-to-day managing patients and communicating with families; often a quick phone call helping them optimize the treatment of an infection is not only welcome but also, the immediate impacts to patient care are often quickly apparent in patient improvement and/or stabilization," he says.

Next: Long-term care

#3. Sharp Coronado Hospital and Villa Coronado LTC, Coronado, California.

Back in 1998, when Bridget Olson, RPh, ASP/ID pharmacist, helped start an ASP, it was a relatively new idea.

Olson

"We originally started Sharp Healthcare’s first ASP at Sharp Cabrillo Hospital [SCH] with a pharmacist, an ID physician and infection control RN," Olson says. "The idea was to combine surveillance and improvement of antibiotic prescribing with the ultimate goal of curbing antibiotic resistance."

A few years later, acute care and emergency services were consolidated and SCH was converted to a sub-acute and long-term care (LTC) facility.

"Our administration showed great foresight in retaining the ASP for the LTC facility," Olson says. "Infections with multidrug-resistant organisms (MDROs) are associated with significant morbidity and mortality in acute care facilities. There is increasing recognition that residents in LTC facilities with multiple comorbidities and advanced age contribute to the MDRO pool."

SCH eventually closed and Olson transferred to Sharp Coronado Hospital & Villa Coronado LTC, a small community facility with 59 acute care beds and 122 LTC beds, where she now has the help of two physician ASP champions, in addition to an ID and an infection preventionist on the ASP team.    

"There were issues with a high rate of C. difficile infections [CDIs], high vancomycin and broad-spectrum antibiotic use, a high vancomycin-resistant enterococci [VRE] rate, and increasing antimicrobial resistance on the LTC side. E. coli sensitivity to quinolones was down to 15% due to widespread quinolone use in the LTC patients. Administrators were concerned about CDI-our recurrence rate was 64%-the rising costs of antibiotics, and were curious about the possibility of an ASP helping to ensure appropriate use and reduce costs of antibiotics," she explains.

Olson created patient monitoring forms for antimicrobials and began prospective reviews with interventions-known as the best way to educate prescribers and to monitor and affect antibiotic use.

"We focused on minimizing empiric quinolone use, de-escalation of therapy after culture results were available, and limiting durations of therapy for pneumonias, skin and soft tissue infections and urinary tract infections," she says.

An ASP was started for acute care in 2010, and LTC was added in 2011. "We ran reports on what was growing in the different infection sites and used antibiogram data and our ID physician's help to establish the best empiric therapies for our patient population," she says.  "In 2012, we began an ID pharmacist student rotation, which helped with daily monitoring of patients on antibiotics, in addition to the development of educational materials to promote ASP knowledge of the staff."

In 2012, the program initiated an LTC fever/suspected infection protocol to help deal with the overuse of antibiotics for patients with a fever and positive culture, but without symptoms. This led to the development of a comprehensive patient assessment form, and education of nurses on the symptoms of infection to look for and report to physician

Villa Coronado LTC uses the McGeer Criteria for Infections in LTC Facilities for definitive symptoms necessary to confirm urinary, respiratory and skin and soft tissue infections.

"We created flow charts useful for reference and education, and computer-based order sets for ease of ordering the ID-recommended therapy, cultures, IV fluids, etc.," Olson says. "Assessments are reviewed by the pharmacist, along with the patient histories and co-morbidities before the doctor is called. The pharmacist helps with treatment recommendations, and advises if criteria are met for antibiotic treatment."

With the longer patient stays in LTC, changes in resistance patterns can be more easily demonstrated. With a greater than 40% reduction in overall antibiotic use since 2011, C. difficile rates have decreased by 80%, VRE rates by 40%, E. coli sensitivity to quinolones increased from 15% to 54%, and Pseudomonas antibiotic susceptibilities are now similar to those on acute care.

Next: C-suite support

#4. Blessing Health System, Quincy, Illinois.

The ASP at Blessing Hospital (BH) began after increased patterns of antibiotic resistance were observed, which included increased resistance for Pseudomonas aeruginosa isolates, an increased prevalence of vancomycin-intermediate Staphylococcus aureus, and increased overall fluoroquinolone resistance, according to Andrea Chbeir, PharmD, BCPS, clinical specialist, cardiology, and clinical pharmacist supervisor.

The ASP team at BH consists of a family physician, several hospitalists, a pharmacist representative from the local long-term care pharmacy, representatives from area nursing homes, clinical pharmacists, microbiologists, infection control, performance improvement consultant, performance improvement data analyst, the chief quality and safety officer, and an epidemiologist.

Chbeir

"BH’s administration has supported the ASP by incorporating stewardship efforts into the job descriptions for all of stewardship team members," Chbeir says. "The program also purchased a CDSS [clinical decision support system], which allows pharmacists to more efficiently identify potential opportunities for stewardship interventions."

The P&T committee and antimicrobial stewardship committee are responsible for the ASP, and there is no single appointed leader. All pharmacists complete the Society of Infectious Disease Pharmacists Certification Program in Antibiotic Stewardship, and provide drug expertise for the program.

The pharmacists monitor antibiotic therapies as well as microbiology results and provide recommendations to modify them when necessary-an action known as prospective audit and feedback," says Chbeir.

Process measures tracked by BH’s ASP include adherence to appropriate use guidelines and clinical pathways, as well as how often antimicrobial therapy is streamlined. Outcome measures tracked by the program include rates of C. difficile, and significant trends in the hospital antibiogram such as prevalence of vancomycin-intermediate Staphylococcus aureus isolates.

There is no “one-size-fits-all” approach to stewardship, says Chbeir. "Many different healthcare settings have taken the same set of guidelines and adapted them to fit their resources and specific needs," she says. "I believe this is the key to a successful program; being able to adapt the concepts of stewardship to what works within each healthcare setting. BH started small with a pilot of four antibiotics to demonstrate the gap between appropriate and actual use to the medical staff directly alongside the antibiogram and the literature that ties it all together. That pilot study became the catalyst for the ASP."