Guest commentary: Keys to successful ASP development
New regulatory requirements from CMS and The Joint Commission that have gone into effect this month require all hospitals and critical access hospitals to implement infection prevention and control and antibiotic stewardship programs, which are now necessary to participate in Medicare and Medicaid. In this guest commentary, Priya Nori, MD, Rachel Bartash, MD, Belinda Ostrowsky, MD, MPH, and the antimicrobial stewardship program team at the Montefiore Health System in the Bronx, New York, draw from their own experiences and discuss how to adapt the CDC’s “Core Elements of Hospital Antibiotic Stewardship Programs” to patients, pathogens, prescribers and personnel.
As much as 50% of all antibiotic prescriptions are considered “inappropriate.” While there is no consensus definition, experts consider antibiotics to be “inappropriate” when they are prescribed for nonbacterial infections, the spectrum of coverage is overly broad and potentially toxic, the dose is inaccurate for the host, or the intended duration is too long. “Inappropriateness” contributes directly to medication side effects, interactions, kidney and liver dysfunction, Clostridium difficile infections, and the emergence of multidrug-resistant pathogens. As early as 1945, Sir Alexander Fleming, the pioneer of the antibiotic era, warned that the overuse of antibiotics “clearly drives the evolution of resistance,” but only recently has antibiotic resistance risen to the forefront of scientific and political agendas.
In his 2014 State of the Union Address, President Obama introduced multidrug resistance (MDR) as a national security issue. He later assembled the President’s Council of Advisors on Science and Technology (PCAST) on antimicrobial resistance, thereby inserting it into the national dialogue. The White House’s National Action Plan committed significant funding to targeting antibiotic resistance and proposed antimicrobial stewardship program (ASP) implementation across all facets of health care by 2020. The Action Plan calls for a substantial reduction in “inappropriate” antibiotic prescribing over the next 3 years by 20% and 50%, respectively, in the inpatient and outpatient arenas. Finally, in 2016, the CMS and the Joint Commission joined the narrative by proposing similar ASP standards across the health care continuum.
Mainstream recognition of the scope of antibiotic resistance allows us to implement meaningful solutions. ASPs, promoting judicious antimicrobial prescribing, are recognized as a crucial defense against antimicrobial resistance on a global scale.
The CDC’s “Core Elements of Hospital Antibiotic Stewardship Programs” provide a framework for successful ASP development. Newly proposed regulatory standards for ASPs also draw from these “Core Elements” (see Table 1).
How can we adapt these Core Elements to our home institutions?
Given vast differences in settings, size and available resources, there is no “one-size fits all” approach. ASPs should be tailored to an individual hospital’s prescribers, patients, pathogens and personnel with expertise in pharmacology and infectious diseases.
Since the inception of Montefiore’s ASP in 2008, we have garnered valuable experiences and lessons learned that are applicable across a range of settings.
Leadership commitment: Hospital leaders must commit financial resources, trained personnel with dedicated time, and a shared philosophy and vision for improved patient outcomes. Ideally, the administration also understands new regulatory requirements, and provides enough support to either initiate or advance your program.
Example: From 2010-2012, our ASP audited antibiotic use patterns at a newly acquired community hospital with concerning rates of MDR and antibiotic overuse. Our ASP presented a business case for a full-time ID pharmacist and ID physician to extend ASP policies and practices to this new campus, based on potential cost savings and improved outcomes. Leadership provided full support, and a new program was implemented in 2013. Within the first 3 years of the program, we have observed decreased rates of antibiotic resistance in gram-negatives and hospital-onset C. difficile infections due to collaborative ASP efforts with frontline clinicians.
Accountability and drug expertise: ASP guidelines propose that lead ASP personnel should include ID-trained physicians and pharmacists; however, this may not be feasible in all settings due to limited available resources and staffing.
Example: In community, public or rural hospitals, clinical pharmacists or post-graduate trainees can partner with the microbiology laboratory to review positive blood cultures and ensure that patients are on appropriate therapy and have received appropriate work-up and ID consultation.
Creative approaches to stewardship have been successful throughout the country, including rural settings and critical access hospitals. These include remote ASPs via telephone, video-conference or internet, and the creation of multidisciplinary stewardship work groups or antibiotic subcommittees formulating policies specific to each institution. Partnership with microbiology is particularly useful when implementing new laboratory workflows or rapid diagnostic technology, such as PCR, matrix-assisted laser desorption ionization time-of-flight mass spectrometry, or MALDI-TOF, etc. In long-term care facilities where overtreatment of asymptomatic bacteriuria is particularly problematic, staff pharmacists or clinicians can review antibiotics prescribed for positive urine cultures with local ASPs or ID programs to develop algorithms for appropriate UTI management.
Action: This refers to any intervention or policy implemented to improve antibiotic prescribing.
Example: An action popularized by the CDC’s “Get Smart about Antibiotics” campaign is the “antibiotic timeout,” which prompts prescribers to reassess the need for ongoing broad-spectrum antibiotics at 48-72 hours and de-escalate or stop antibiotics based on a patient’s clinical status, labs, cultures or imaging. The “antibiotic timeout” can also be linked to electronic order entry systems as a “best practice alert.”
For programs with intermittent availability of trained ASP personnel, linking audit and feedback to “antibiotic timeouts” is a feasible “back-end” intervention.
Tracking and reporting: Monitoring antibiotic prescribing patterns is essential for understanding how practices evolve, before and after implementation of your ASP. Furthermore, reporting patterns back to providers helps to reinforce best practices and identify and remedy any outliers.
Example: Recent notable studies have shown that up to one of three outpatient antibiotic prescriptions are inappropriate. In 2016, we collaborated with the United Hospital Fund, the Greater New York Hospital Association and other New York hospital systems in a pilot program exploring health care provider motivators and perceptions on antibiotic prescribing for acute respiratory tract infections. We evaluated existing ambulatory ASP activities and tracked antibiotic prescriptions from multiple clinics to give feedback to providers on volume, appropriateness and comparative patterns of antibiotic use.
Education: Education on appropriate prescribing for a range of inpatient and outpatient infections is the foundation of any ASP. Active education with interactive tools is gaining popularity and acceptance among students, trainees and mature clinicians.
Example: In 2014, with support from the Albert Einstein College of Medicine, we created an antibiotic prescribing app, “APPropriate Use,” containing treatment guidelines and local antibiograms to help medical students select “the right drug for the most likely bug.” Based on its success among students, we later developed “APPropriate Use, 2.0” with clinical algorithms, isolation precautions and local antibiograms for all prescribers at Montefiore. We launched the app during the CDC’s “Get Smart about Antibiotics” week in November 2015 as an outreach activity promoting judicious antibiotic use.
For the first time in history, antibiotic resistance is globally recognized as a threat to public safety and security. While ASPs are increasingly invoked in the fight against antibiotic resistance, our programs will likely be viewed “under the microscope” of new regulatory standards in the coming decade. There may be no “one-size fits all” approach to stewardship, but individual facilities can adapt the CDC’s Core Elements to meet their specific needs.
CDC. Core Elements of Hospital Antibiotic Stewardship Programs. https://www.cdc.gov/getsmart/healthcare/implementation/core-elements.html. Accessed December 21, 2016.
CDC. Measuring Outpatient Antibiotic Prescribing. https://www.cdc.gov/getsmart/community/programs-measurement/measuring-antibiotic-prescribing.html#f4. Accessed December 21, 2016.
New York Times. Penicillin's finder assays its future. June 26, 1945; p. 21.
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Rachel Bartash, MD, is a second-year infectious diseases fellow at Montefiore Health System. She received an MD from Albert Einstein College of Medicine and completed her internal medicine residency at the University of Michigan. Bartash served as a clinical instructor in the division of general medicine at the University of Michigan and staff physician at the Veterans Affairs Ann Arbor Healthcare System. Her clinical and research interests include infectious diseases, antimicrobial stewardship, and infection control.
Priya Nori, MD, is the medical director of antibiotic stewardship at Montefiore Health System. A graduate of Johns Hopkins University and the Albert Einstein College of Medicine, Nori trained as an intern at the Baylor College of Medicine and as a resident in internal medicine at the NewYork-Presbyterian/Weill Cornell Medical Center before coming to Montefiore to complete a fellowship in infectious diseases. In 2013, Nori joined Montefiore’s faculty, where she has had a major role in antibiotic stewardship as director of the program at the Wakefield campus. Nori’s awards include the American Medical Women’s Association Glasgow-Rubin Achievement Award, Alpha Omega Alpha, and the Barbara Zucker Traveling Fellowship in Clinical Infectious Diseases. Her research currently focuses on antimicrobial stewardship, with emphasis on improving evidence-based antibiotic prescribing in medical providers.
Belinda Ostrowsky, MD, MPH, is director of epidemiology, stewardship and infection prevention at Montefiore Health System. Ostrowsky joined Montefiore in 2008, having graduated summa cum laude from the City University of New York, receiving an MD from SUNY Stony Brook University School of Medicine, and completing a residency in internal medicine at the Mayo Clinic in Rochester, Minnesota, and a fellowship in infectious diseases at the Beth Israel Deaconess Medical Center in Boston. She earned her MPH from the Harvard T.H. Chan School of Public Health and devoted 2 years to the Epidemic Intelligence Service of the CDC. Ostrowsky is a fellow of the Infectious Diseases Society of America, and is an active member of the Society for Healthcare Epidemiology of America and the Council of State and Territorial Epidemiologists.
Disclosures: Bartash, Nori and Ostrowsky report no relevant financial disclosures.