Antimicrobial stewardship: A work in progress
In this commentary, Infectious Disease News Editorial Board member Ellie J.C. Goldstein, MD, clinical professor of medicine at David Geffen School of Medicine at the University of California, Los Angeles, discusses several presentations at IDWeek 2015 that focused on antimicrobial stewardship, as well his own experiences in California, which is currently the only state to enact antimicrobial stewardship legislation.
The CMS and the CDC have strongly recommended the formation of antimicrobial stewardship programs in acute care hospitals. CMS has proposed several elements for antimicrobial stewardship, including a multidisciplinary process to review antimicrobial utilization and local susceptibility patterns, systems such as computerized physician order entry and formulary restrictions to prompt appropriate use of antimicrobial agents, antibiotic orders that include an indication for use, a mechanism to prompt clinician review of antibiotic courses of therapy after 72 hours of treatment (“antibiotic timeout”) and systems in place to identify patients currently receiving IV antibiotics who might be eligible for oral antibiotic treatment.
Ellie J.C. Goldstein
Antimicrobial stewardship received a considerable amount of attention during IDWeek 2015 in San Diego. At present, validated standardized metrics to gauge the performance of an antimicrobial stewardship program (ASP) are lacking, according to Keith Teelucksingh, PharmD, BCPS-AQ-ID, division director of infectious disease pharmacy for HCA’s South Atlantic Division in Charleston, South Carolina, who gave a presentation on hospital antimicrobial stewardship as a quality indicator. At his facility, the metrics being tracked are utilization — currently in defined daily doses with a plan to shift to days of therapy in 2016 — and adjusted spend of targeted agents.
While not a quality metric, Teelucksingh emphasized the importance of educational efforts to stewardship, especially in the training of new residents, which can lead to the most sustainable gains in appropriate antimicrobial use. In the future, expect the use of information technology systems in capturing metrics, the benchmarking of antimicrobial use by facility location (ie, medical/surgical floor, ICU, etc.) and more engagement with departments in quality.
Several states have implemented antimicrobial stewardship activities within the domain of public health. In my presentation that followed, I provided observations from California, a state with antimicrobial stewardship legislation. Senate Bill 739 was approved by the governor in 2006, and requires that general acute care hospitals develop a process for evaluating the judicious use of antibiotics, and the results to be monitored jointly by representatives and committees involved in quality improvement. Each hospital was left to independently comply. The effect of this legislation was measured via a survey in 2010-2011, in which 50% of acute care hospitals reported having an ASP, and 22% reported that Senate Bill 739 influenced the initiation of an ASP.
The Infectious Disease Association of California (IDAC), a recognized specialty organization by the California Medical Association, was asked to sponsor a bill with the intent of improving legislative regulations by requiring additional health care-associated infection reporting. IDAC indicated the inadequacy of additional data collection and reporting without addressing the causes of antimicrobial resistance, and it suggested a focus on elements of antimicrobial stewardship. The result was Senate Bill 1311, which was signed into law in September 2014 and became effective on July 1.
Basic elements of Senate Bill 1311 include:
- adoption and implementation of antimicrobial stewardship policy in accordance with guidelines established by the federal government and professional organizations;
- establishment of a physician-supervised multidisciplinary antimicrobial stewardship committee comprised of at least one physician or pharmacist who has undergone specific training related to stewardship, recognizing that the role of clinical infectious disease physicians is exceedingly important to understand the entire scope of an ASP; and
- reporting of ASP activities to appropriate hospital committees undertaking quality improvement activities.
A set of intermediate and advanced elements, which include development of an annual antibiogram, monitoring of antibiotic usage patterns using days of therapy or defined daily doses, prospective audits and formulary restriction with preauthorization, were among 11 elements defined by the California Department of Public Health.
Examples of suggested ASP activities include medication use evaluations, an assessment of the acceptance rate of ASP interventions and a monthly restricted antibiotic report to identify resistance to ASP. Quarterly reports of antimicrobial expenditures and antimicrobial use (days of therapy or defined daily doses) also are recommended.
Other aspects of ASP that we perform in our hospitals are monitoring the duration of therapy for specific indications and the use of multiple drug therapy, as a means to limit the emergence of resistance and the development of Clostridium difficile infection (CDI), which eventually is expected to be incorporated into hospital performance measures. Microbiology, or “culture” stewardship that ensures sufficient quality of a culture on which to base a therapeutic decision, is an important piece of our ASP.
As Teelucksingh explained, we must have defined ASP metrics that are not the same for each type of institution. In addition, the electronic health record must be constructed to guarantee effective transitions of care.
Pediatrics is a burgeoning field for which antimicrobial stewardship has rarely been investigated. In a poster presentation, Jean Wiedeman, MD, PhD, associate professor of pediatric infectious diseases at the University of California Davis Children’s Hospital in Sacramento, described the effect of implementing an ASP, demonstrating a threefold reduction in the development of CDI compared with the era prior to the ASP, and an annual savings of $56,040 in antibiotic-related costs at the 110-bed pediatric facility. The ASP utilized multiple forms of intervention, including audit of charts and the requirement for preauthorization for use of restricted antimicrobials.
During the final day of IDWeek 2015, two new bills were approved in California. Senate Bill 361 extends antimicrobial stewardship guidelines to skilled nursing facilities, which tend to be reservoirs of resistance and C. difficile. The second is Senate Bill 27, which states that medically important antimicrobials not be administered to livestock for the purpose of enhancing weight or improving feed efficiency.
Doubtless, stewardship programs should and will eventually be adopted nationally. It is unclear what form they will take, but the various levels of stewardship must be based on the hospital type and the resources available. Antimicrobial stewardship is a work in progress, and the value of various interventions will be teased out as more studies are conducted. – by Ellie J.C. Goldstein, MD
Goldstein E. Experiences From the State of California. Presented at: IDWeek; Oct. 7-11, 2015; San Diego.
Nakra N, et al. Antimicrobial Cost Savings and Reduction in Clostridium Difficile Infection Rates Following Implementation of a Pediatric Antimicrobial Stewardship Program. Presented at: IDWeek; Oct. 7-11, 2015; San Diego.
Teelucksingh K. Hospital Antimicrobial Stewardship as a Quality Indicator. Presented at: IDWeek; Oct. 7-11, 2015; San Diego.
Disclosure: Goldstein reports no relevant financial disclosures.