Hospitals and health systems with effective antimicrobial stewardship programs see lower costs for both payer and provider in addition to improved patient outcomes. As an industry-leading healthcare solutions provider, Wolters Kluwer explores the 8 core elements recommended by the CDC and The Infectious Disease Society of America and how these make an impact.
Eight core elements of a Successful Antimicrobial Stewardship Program
Recommendations from the CDC and the Infectious Disease Society of America (IDSA) encourage all AMS programs to include the following eight elements:
Hospital leadership commitment: dedicate human, financial, and technological resources
Support includes both a formal, written statement endorsing efforts to improve antimicrobial stewardship as well as dedicated time and resources to support AMS activities, salaries, training, and IT support. Words alone will not get a program executed, funding without overt leadership support risks more pushback from physicians and staff. Program leadership should have regularly scheduled meetings with senior executives and the board to report activities and outcomes
Accountability: appoint a leader(s) for program management and outcomes
A leader or co-leaders, preferably a physician and/or pharmacist with infectious disease training, provides an invaluable communication link and source of credibility with medical staff, particularly senior physicians who may be more resistant. The leader(s) also accepts accountability for the program and communicates with hospital administration. Do you have a clinician who is clearly in charge of your AMS program? If so, is this clinician’s time spent on antimicrobial stewardship adequately? That’s an important next step to ensure the leader can devote sufficient time and energy to making sure the program succeeds.
Pharmacy expertise: appoint a pharmacist to lead implementation efforts to improve antibiotic use
A pharmacist provides essential drug expertise and may serve as co-leader of the antimicrobial stewardship program. If the designated pharmacist has infectious disease training, that is even better.
The importance of a dedicated Infectious Disease Pharmacist as part of an AMS program may prove to be an invaluable aspect of improving the patient care experience and overall healthcare costs.
Yu et al. conducted a retrospective pre and post-ASP implementation study with historical controls and comparison groups conducted within a large health care system composed of 14 medical centers. The study centered around two sites over 12 months, site 1 was a 250- bed community facility with average antimicrobial usage, and site 2 was a 396-bed tertiary care teaching facility with a lower reported antimicrobial usage.
The ASP team at each trial site consisted of an ID pharmacist and physician. Examples of pharmacist interventions include:
- therapy discontinuation or de-escalation
- iv to oral conversion
- change in therapy based upon culture or laboratory data.
Upon completion of the study, the utilization of all classes of antibiotics decreased. The trial sites also appreciated a decrease in antimicrobial cost per 1000 patient days. The hospital standardized mortality ratio values for respiratory infections and sepsis improved, while the rate of C. difficile occurrence remained unchanged. These sites also experienced an aggregate savings of ~ $228K.
Actions and interventions: Implement interventions to improve antibiotic use
Prospective audit and feedback, preauthorization, and facility-specific treatment recommendations should be your first priorities, then add from the lists here and on the CDC checklist:
- Infection-based interventions targeting respiratory tract infections, urinary tract infections, and skin and soft tissue infections. Examples may include improving diagnostic testing, review of microbiology results and adjusting therapies, and monitoring duration of therapies.
- Provider-based interventions such as antibiotic timeouts at 48 hours and allergy assessments
- Pharmacy-based interventions such as making the switch to oral antibiotic therapy from intravenous automatic when appropriate, dose optimization, documentation of indications, and duplicative therapy alerts
- Microbiology-based interventions such as selective reporting of susceptibilities and adding comments in reports to help clinicians interpret the results
- Nursing-based interventions such as education on proper techniques in obtaining specimens to reduce contamination.
Tracking: Monitor antibiotic prescribing, the impact of interventions, and other important outcomes like C. difficile infection and resistance patterns.
Continuous improvement and ongoing funding depend on documenting and communicating results to both hospital administrators and to prescribers. Antibiotic usage should be tracked closely to determine the impact of AMS interventions. Sending usage data electronically to the National Healthcare Safety Network enables hospitals to benchmark their own performance using the Standardized Antimicrobial Administration Ratio (SAAR). Other outcomes to consider may include C. difficile infection, resistance patterns, and financial metrics. Tracking and reporting on compliance with documentation policies is also important. Hospitals then often add reporting on adherence to facility-specific treatment recommendations and pharmacy interventions by unit and prescriber, with feedback to all clinicians.
Reporting: Share information on antibiotic use and resistance to prescribers, pharmacists, nurses, and hospital leadership.
AMS programs should operate transparently to ensure continual commitment from all stakeholders. Process and outcome measures should be shared regularly with prescribers, pharmacists, nurses, and leadership.
Education: Educate clinical teams on adverse reactions from antibiotics, antibiotic resistance, and optimal prescribing.
Clinicians and staff need to understand why antimicrobial stewardship matters and how the hospital plans to improve its stewardship and what they need to do to help. Ongoing education is a critical component of all high-performing AMS programs. Case-based education in the setting of prospective audit or preauthorization can be particularly timely and effective with prescribers.
Kubin et al, detailed the critical need for ASP pharmacists at New York-Presbyterian Hospital during the COVID-19 pandemic, an academic medical hospital system containing 6 acute care hospital systems, 2 medical schools and ~2500 beds. Roles of the ASP pharmacist include but are not limited to:
- development and maintenance of clinical guidelines
- dose optimization
- prescriber education
- approval of restricted anti-infectives.
A rapidly changing landscape during such a challenging time, caused the pharmacists to become creative in their educational efforts. Examples of AMS education include:
- Developing new treatment guidelines in concert with changes in literature
- Sharing updates to therapy recommendations with pharmacists and physicians
- Including attestations and informational links within prescriber ordering of experimental agents
- Implementing prescriber ordering restrictions as needed to change with practice
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