Commentary

Antimicrobial stewardship: California and beyond

Antimicrobial stewardship is currently one of the most popular buzzwords in infectious diseases. The concept of antimicrobial stewardship should have been a basic tenet of medical training since the discovery of penicillin by Sir Alexander Fleming in 1928. However, recent studies show that up to 30% of antimicrobials prescribed in the hospital and 22% to 89% of antimicrobials in long-term care facilities remain inappropriate or suboptimal.

Evidence that current medical and residency training is insufficient, ineffective, or unable to change the culture of overprescribing has been documented: 92% of the fourth-year medical students surveyed at three prestigious medical schools said strong knowledge of antimicrobials is important in their careers, but only one-third felt adequately prepared in the fundamental principles of antimicrobial use.

Guidelines created to combat resistance

It is generally accepted that antimicrobial resistance directly reflects the frequency of use of various antimicrobial agents with an impact on selective pressure. Even in 1979, Ma and colleagues wrote about a single institution’s experience with the development of resistance in gram-negative bacilli due to antibiotic use. In 2007, the Infectious Diseases Society of America and Society of Hospital Epidemiology of America (SHEA) produced guidelines for developing multifaceted “institutional programs to enhance antimicrobial stewardship, an activity that includes appropriate selection, dosing, route, and duration of antimicrobial therapy” with the goal of optimizing “clinical outcomes while minimizing unintended consequences of antimicrobial use, including toxicity, the selection of pathogenic organisms … and the emergence of resistance.” Most resistant pathogens have no survival advantage over their susceptible relatives other than their resistance to antimicrobial agents, and they are usually less fit. Remove the agents and their survival advantage is also removed.

Pressure to establish stewardship programs

The issues of patient safety when using unnecessary and inappropriate medications coupled with an increasing financial burden of health care-associated infections (HAIs) due to resistant organisms has gained the attention of the press, public, health insurance industry, state legislators, US Congress, President Obama and the health insurance industry. This has increased the selective pressure on hospitals and clinicians to establish antimicrobial stewardship programs (ASPs).

Kavita K. Trivedi

Ellie J.C. Goldstein

California is the only state to require hospitals to monitor antibiotic use to date, although “the law neither specifies the process, nor addresses noncompliance, it provides incentive for hospital administrators to establish active ASPs.” California enacted Senate Bill 739 in 2006, which established the HAI Program at the California Department of Public Health (CDPH). The HAI Program is mandated to conduct HAI surveillance, prevention and annual reporting in all general acute care hospitals as well as mandatory public reporting of specific process measures. Legislation enacted in 2008 subsequently mandated HAI-specific public reporting. Of note, Senate Bill 739 also established the California HAI Advisory Committee, which is required to provide recommendations related to public reporting and the use of national guidelines for HAI prevention to CDPH. One such recommendation, made in February 2011, requires a formal education course on ASPs for the hospital ASP physician and pharmacy champion. A policy statement issued by IDSA, SHEA and the Pediatric Infectious Diseases Society in 2012 also emphasized that individual facilities should be responsible for supporting the education of the members of the ASP. While recommended by the HAI Advisory Committee in California, this is not yet required, although new legislation is being proposed.

Specific wording of Senate Bill 739, under California Health & Safety Code 1288.8.a, stipulates that “by Jan. 1, 2008, [CDPH] shall take all of the following actions to protect against health care-associated infections in general acute care hospitals statewide: Require that general acute care hospitals develop a process for evaluating the judicious use of antibiotics, the results of which shall be monitored jointly by appropriate representatives and committees involved in quality improvement activities.”

Without a regulatory backbone as of yet, the HAI Program’s interpretation of the law is that each general acute care hospital in California have an ASP, making California the first and still only state in the United States to enact such legislation.

Initiative stimulates program development

CDPH has gradually established infrastructure to support this unfunded mandate via the California ASP initiative. This initiative was started in February 2010 as a part of the HAI Program. The objective of the California ASP initiative has been to assist all California hospitals and long-term care facilities to optimize antimicrobial use to improve patient outcomes. Specific activities of the California ASP initiative have been to assess ASPs statewide, assist hospitals to develop/strengthen ASPs, provide data for administrative buy-in, identify successful setting-specific strategies, develop regional collaborations and strengthen legislation/regulations surrounding stewardship. A 2010-2011 assessment of ASPs in California determined that California Senate Bill 739 was influential in stimulating the development of 22% of ASPs in responding hospitals, supporting similar legislation in other states. Of the 223 respondents, many of which were community hospitals, 50% described a current ASP, and of these, 51% reported measuring outcomes.

The California ASP initiative is continuing to assist health care facilities to best levy their own resources in fostering successful, facility-specific ASPs. In addition, it is the economic and fiduciary responsibility of physicians, hospital administration and hospital staff to establish ASPs for the primary purpose of improving the quality of patient care with collateral benefits on reducing costs and limiting the development of resistance. This work should add to the impetus for other states and potentially the federal government to follow California’s lead. It should also serve as an impetus for medical schools and residency programs to initiate ASP training as a formal part of their curricula.

In conclusion, California is the only state to require hospitals to monitor judicious use of antibiotics to date. The California ASP Initiative was established to support this unfunded mandate and has uncovered a huge need for education, guidance and benchmarking related to ASPs. Thus far, the initiative has mobilized current state momentum by assisting hospitals and long-term care facilities in developing ASPs and provides a model for other similar state initiatives.

References:

Abbo LM. Clin Infect Dis. 2013;57:631-638.
Andersson DI. Nat Rev Microbiol. 2010;8:260-271.
California Department of Public Health. The California Antimicrobial Stewardship Program Initiative. www.cdph.ca.gov/programs/hai/Pages/AntimicrobialStewardshipProgramInitiative.aspx. Last updated March 4, 2014. Accessed April 21, 2014.
Cosgrove SE. Infect Control Hosp Epidemiol. 2012;33:374-380.
Dellit TH. Clin Infect Dis. 2007;44:159-177.
Goldstein EJC. Infect Dis Clin Pract. 2012;20:294-296.
Loeb M. Infect Control Hosp Epidemiol. 2001;22:120-124.
Ma M. Am J Hosp Pharm. 1979;36:1055-1058.
Ma MY. Antimicrob Agents Chemother. 1983;24:347-352.
SHEA. Infect Control Hosp Epidemiol. 2012;33:322-327.
Trivedi KK. Infect Control Hosp Epidemiol. 2013;34:379-384.

For more information:

Kavita K. Trivedi MD, is principal at Trivedi Consults, LLC, in Albany, Calif., and is adjunct clinical associate professor of medicine at Stanford University School of Medicine. She can be reached at kavita@trivediconsults.com.
Ellie J.C. Goldstein MD, is director of infection control at Kindred Hospital – Los Angeles; director of the RM Alden Research Laboratory in Santa Monica, Calif.; and clinical professor of medicine at The David Geffen School of Medicine at UCLA, Los Angeles. Goldstein is also a member of the Infectious Disease News Editorial Board. He can be reached at ejcgmd@aol.com.

Disclosure: Goldstein and Trivedi report no relevant financial disclosures.

Antimicrobial stewardship is currently one of the most popular buzzwords in infectious diseases. The concept of antimicrobial stewardship should have been a basic tenet of medical training since the discovery of penicillin by Sir Alexander Fleming in 1928. However, recent studies show that up to 30% of antimicrobials prescribed in the hospital and 22% to 89% of antimicrobials in long-term care facilities remain inappropriate or suboptimal.

Evidence that current medical and residency training is insufficient, ineffective, or unable to change the culture of overprescribing has been documented: 92% of the fourth-year medical students surveyed at three prestigious medical schools said strong knowledge of antimicrobials is important in their careers, but only one-third felt adequately prepared in the fundamental principles of antimicrobial use.

Guidelines created to combat resistance

It is generally accepted that antimicrobial resistance directly reflects the frequency of use of various antimicrobial agents with an impact on selective pressure. Even in 1979, Ma and colleagues wrote about a single institution’s experience with the development of resistance in gram-negative bacilli due to antibiotic use. In 2007, the Infectious Diseases Society of America and Society of Hospital Epidemiology of America (SHEA) produced guidelines for developing multifaceted “institutional programs to enhance antimicrobial stewardship, an activity that includes appropriate selection, dosing, route, and duration of antimicrobial therapy” with the goal of optimizing “clinical outcomes while minimizing unintended consequences of antimicrobial use, including toxicity, the selection of pathogenic organisms … and the emergence of resistance.” Most resistant pathogens have no survival advantage over their susceptible relatives other than their resistance to antimicrobial agents, and they are usually less fit. Remove the agents and their survival advantage is also removed.

Pressure to establish stewardship programs

The issues of patient safety when using unnecessary and inappropriate medications coupled with an increasing financial burden of health care-associated infections (HAIs) due to resistant organisms has gained the attention of the press, public, health insurance industry, state legislators, US Congress, President Obama and the health insurance industry. This has increased the selective pressure on hospitals and clinicians to establish antimicrobial stewardship programs (ASPs).

Kavita K. Trivedi

Ellie J.C. Goldstein

California is the only state to require hospitals to monitor antibiotic use to date, although “the law neither specifies the process, nor addresses noncompliance, it provides incentive for hospital administrators to establish active ASPs.” California enacted Senate Bill 739 in 2006, which established the HAI Program at the California Department of Public Health (CDPH). The HAI Program is mandated to conduct HAI surveillance, prevention and annual reporting in all general acute care hospitals as well as mandatory public reporting of specific process measures. Legislation enacted in 2008 subsequently mandated HAI-specific public reporting. Of note, Senate Bill 739 also established the California HAI Advisory Committee, which is required to provide recommendations related to public reporting and the use of national guidelines for HAI prevention to CDPH. One such recommendation, made in February 2011, requires a formal education course on ASPs for the hospital ASP physician and pharmacy champion. A policy statement issued by IDSA, SHEA and the Pediatric Infectious Diseases Society in 2012 also emphasized that individual facilities should be responsible for supporting the education of the members of the ASP. While recommended by the HAI Advisory Committee in California, this is not yet required, although new legislation is being proposed.

Specific wording of Senate Bill 739, under California Health & Safety Code 1288.8.a, stipulates that “by Jan. 1, 2008, [CDPH] shall take all of the following actions to protect against health care-associated infections in general acute care hospitals statewide: Require that general acute care hospitals develop a process for evaluating the judicious use of antibiotics, the results of which shall be monitored jointly by appropriate representatives and committees involved in quality improvement activities.”

Without a regulatory backbone as of yet, the HAI Program’s interpretation of the law is that each general acute care hospital in California have an ASP, making California the first and still only state in the United States to enact such legislation.

Initiative stimulates program development

CDPH has gradually established infrastructure to support this unfunded mandate via the California ASP initiative. This initiative was started in February 2010 as a part of the HAI Program. The objective of the California ASP initiative has been to assist all California hospitals and long-term care facilities to optimize antimicrobial use to improve patient outcomes. Specific activities of the California ASP initiative have been to assess ASPs statewide, assist hospitals to develop/strengthen ASPs, provide data for administrative buy-in, identify successful setting-specific strategies, develop regional collaborations and strengthen legislation/regulations surrounding stewardship. A 2010-2011 assessment of ASPs in California determined that California Senate Bill 739 was influential in stimulating the development of 22% of ASPs in responding hospitals, supporting similar legislation in other states. Of the 223 respondents, many of which were community hospitals, 50% described a current ASP, and of these, 51% reported measuring outcomes.

The California ASP initiative is continuing to assist health care facilities to best levy their own resources in fostering successful, facility-specific ASPs. In addition, it is the economic and fiduciary responsibility of physicians, hospital administration and hospital staff to establish ASPs for the primary purpose of improving the quality of patient care with collateral benefits on reducing costs and limiting the development of resistance. This work should add to the impetus for other states and potentially the federal government to follow California’s lead. It should also serve as an impetus for medical schools and residency programs to initiate ASP training as a formal part of their curricula.

In conclusion, California is the only state to require hospitals to monitor judicious use of antibiotics to date. The California ASP Initiative was established to support this unfunded mandate and has uncovered a huge need for education, guidance and benchmarking related to ASPs. Thus far, the initiative has mobilized current state momentum by assisting hospitals and long-term care facilities in developing ASPs and provides a model for other similar state initiatives.

References:

Abbo LM. Clin Infect Dis. 2013;57:631-638.
Andersson DI. Nat Rev Microbiol. 2010;8:260-271.
California Department of Public Health. The California Antimicrobial Stewardship Program Initiative. www.cdph.ca.gov/programs/hai/Pages/AntimicrobialStewardshipProgramInitiative.aspx. Last updated March 4, 2014. Accessed April 21, 2014.
Cosgrove SE. Infect Control Hosp Epidemiol. 2012;33:374-380.
Dellit TH. Clin Infect Dis. 2007;44:159-177.
Goldstein EJC. Infect Dis Clin Pract. 2012;20:294-296.
Loeb M. Infect Control Hosp Epidemiol. 2001;22:120-124.
Ma M. Am J Hosp Pharm. 1979;36:1055-1058.
Ma MY. Antimicrob Agents Chemother. 1983;24:347-352.
SHEA. Infect Control Hosp Epidemiol. 2012;33:322-327.
Trivedi KK. Infect Control Hosp Epidemiol. 2013;34:379-384.

For more information:

Kavita K. Trivedi MD, is principal at Trivedi Consults, LLC, in Albany, Calif., and is adjunct clinical associate professor of medicine at Stanford University School of Medicine. She can be reached at kavita@trivediconsults.com.
Ellie J.C. Goldstein MD, is director of infection control at Kindred Hospital – Los Angeles; director of the RM Alden Research Laboratory in Santa Monica, Calif.; and clinical professor of medicine at The David Geffen School of Medicine at UCLA, Los Angeles. Goldstein is also a member of the Infectious Disease News Editorial Board. He can be reached at ejcgmd@aol.com.

Disclosure: Goldstein and Trivedi report no relevant financial disclosures.