What's on Your Antimicrobial Stewardship "Wish List"?

With the development of the US Centers for Disease Control and Prevention’s Core Elements of Hospital Antibiotic Stewardship Programs in 2014 followed by the Joint Commission stan­dard for inpatient antimicro­bial stewardship in 2017, many hospitals have either created or improved their antibiotic stew­ardship programs (ASPs).^1-3

Institutions have invested resources to ensure that their programs meet the minimum requirements to comply with the standard, but what if cost wasn’t an issue?

Beyond the antimicrobial stewardship requirements described in the Joint Commission standard,¹ various enhance­ments have the potential to dramatically boost the impact of an ASP. If resources and funds were unlimited, what would the ideal stewardship program look like?

The following wish list includes the perspectives of 2 commu­nity-teaching hospital stewardship pharmacists on items that would be “nice to have” and those they “dream to have.”

NICE TO HAVE

Information Technology (IT) Specialist

As with all quality improvement initiatives, regular evaluation of pertinent metrics is essential in the evaluation of ASP successes and opportunities. Many programs rely on staff to compile and assess metrics, which may be time-consuming and can displace patient care activities. Incorporating an IT specialist with dedicated responsibility for ASP metrics can alleviate this issue, with the added benefit of expertise for higher-level data generation. Dedicated IT resources can also help navigate the requirements for reporting to the National Healthcare Safety Network Antimicrobial Use and Resistance (AUR) Module, allowing for robust interhospital benchmarking.

Various studies have demonstrated the benefits of lever­aging behavioral interventions, such as peer compar­ison, to positively influence antibiotic prescribing.^4,5 Peer comparisons typically involve a report or dashboard of various metrics detailing prescriber-level practices and outcomes. An IT specialist’s expertise is critical in the development of such dashboards, and consistent involvement of the IT specialist for regular maintenance of these metrics is likely necessary for sustained impact on prescribing practices.

Passive stewardship interventions, such as developing guidelines and provider education, may have some immediate impact but lack sustainability.⁶ However, incorporating such guidelines and education at the point of prescribing through the electronic medical record (EMR) may overcome these issues. As use of the EMR becomes a mainstay of health care, it is clear that IT specialists can be valuable members of health care team. In the past 5 years, nearly 100 publications indexed by PubMed have described EMR enhancements that optimize antimicrobial prescribing. The IT specialist can assist an ASP in building several clinical decision support tools within the EMR, such as order sets, clinical pathways, and best practice alerts.

Outpatient Collaboration with Dedicated Outpatient Stewardship Personnel

Structured antimicrobial stewardship programs have been advocated in the inpatient setting for many years to reduce the emergence of resistant pathogens and Clostridium difficile. However, similar efforts are not yet as widespread outside the acute care setting. Collaboration with providers in outpatient and skilled nursing facility (SNF) settings can be beneficial in recognizing the burden of resistance and C difficile across the entire health care continuum.7 A dedicated outpatient stewardship human resource can oversee the development of local outpatient and SNF antibiograms, clinical pathways/ guidelines, and metrics.

Microbiology Resources

The benefits of a strong collaboration with the microbiology laboratory department cannot be overstated. Purposeful modi­fications of the culture and antibiotic susceptibility reports can have significant effects on definitive antibiotic selection. Cascade reporting is the practice of reporting the results of broad-spectrum antibiotics only in response to resis­tance to narrow-spectrum antibiotics in an effort to guide de-escalation. Several studies have demonstrated improve­ments in appropriate selection of narrow-spectrum definitive therapy.^8-10 In addition, including interpretive comments within antibiotic susceptibility reports may improve the utility of these results by embedding therapy recommendations to guide appropriate antibiotic selection. For example, one study evaluated the impact of including a “nudge” comment within respiratory culture results demonstrating isolation of normal flora. The comment specifically addressed lack of substantial growth of Staphylococcus aureus and Pseudomonas aeruginosa, resulting in higher rates of de-escalation/discon­tinuation and lower rates of acute kidney injury, with no adverse outcomes observed.11 Initial implementation of these microbiology enhancements may be resource intensive, but sustained benefit can be seen without the need for long-term dedicated resources.

In addition, the widescale availability of various rapid diag­nostic tests (RDTs) has introduced exciting opportunities for optimization of antimicrobial stewardship.¹² These methods include multiplex polymerase chain reaction (PCR) panels, matrix-assisted laser desorption/ionization time-of-flight mass spectrometry, peptide nucleic acid fluorescent in situ hybridization, morphokinetic cellular analysis, nanoparticle probe technology, and magnetic resonance technology.13 These methods differ in ability to detect various organisms and/or resistance mechanisms but generally offer a faster turnaround compared with traditional culture-based methods, resulting in improved time to appropriate therapy. Although RDTs are attractive wish list items for ASPs, additional steward­ship personnel may be needed to respond to results with appropriate interventions in a timely manner. For the full benefit to be realized, RDTs should be coupled with active ASP engagement, as demonstrated in previous studies.¹⁴

Many technological platforms have a variety of products to address different infectious disease syndromes. Unfortunately, due to cost and space constraints, laboratories are gener­ally unable to purchase several platforms to use the most robust products for each syndrome. For example, a facility that uses a platform that performs multiplex PCR testing for respiratory illness may have the option to purchase panels for rapid blood culture identification that could be run on the same platform as discounted pricing. At this time, these panels are unable to provide robust resistance markers or rapid susceptibility information. Morphokinetic cellular anal­ysis can offer rapid organism identification and phenotypic susceptibility but would require the purchase of an additional testing platform. The ability to use several testing platforms could provide new opportunities to enhance ASPs.

DREAM TO HAVE

Stewardship Transitions-of-Care (TOC) Pharmacist

Antibiotic duration of therapy continues to be a topic of discussion, with more data becoming available for various disease states to suggest shorter durations of therapy.^15,16 Despite several randomized controlled trials demonstrating similar outcomes and guideline endorsement for shorter durations of therapy, a recent study demonstrated that more than two-thirds of patients treated for pneumonia were prescribed excessive antibiotic treatment durations, predominantly at discharge.17 Although TOC has generally focused on chronic disease states (eg, chronic obstructive pulmonary disease, heart failure), antibiotic review at the time of discharge, including antibiotic selection and duration of therapy, has surfaced as an unmet need.^17-20 Adding a dedi­cated TOC pharmacist to focus on antimicrobial steward­ship could decrease overall antibiotic use and, in turn, reduce antibiotic-associated adverse events and possibly C difficile.

Infectious Diseases/Stewardship Data Abstractor

After implementing all the incredible stewardship initiatives that take place day to day, stewards may find that lack of time and resources keep them from evaluating and fully scrutinizing data to determine the intiatives’ impact on patient outcomes. Performing in-depth chart reviews for each intervention in an institution that has 1 dedicated antimicrobial steward generally takes time away from the daily activities required to sustain a stewardship program. Having a dedicated data abstractor for infectious diseases and antimicrobial stew­ardship would allow data to be collected (with possible publi­cation) without compromising daily stewardship activities.

Hospitalist/Stewardship Collaboration

IDWeek 2019 had several sessions describing the impact of including a hospitalist as part of the ASP team. Tejal Gandhi, MD, of the University of Michigan presented data on a large ASP/hospitalist collaborative that showed a signif­icant increase in appropriate duration of antibiotic therapy for community-acquired pneumonia that, in turn, decreased antibiotic-associated adverse events.²¹ Part of the collabo­rative included financial incentives for prescribing appro­priate duration of therapy, which was described by Valerie Vaughn, MD, during the IDWeek session “Collaboration with Hospitalists.”²² Having sufficient funds to give a hospitalist champion dedicated time for stewardship efforts and offer hospitalists antimicrobial stewardship financial incen­tives could potentially affect a large portion of inpatient and outpatient antibiotic use.

Although many of the ideal human resources described above are considered wish list items, business models are being proposed in the literature to help support these resources as standard of care.²³

Patel is an infectious diseases clinical pharmacist at Morristown Medical Center in New Jersey, where she is an active member of the antimicrobial stewardship program.King is an infectious diseases clinical pharmacist at Overlook Medical Center in Summit, New Jersey, where she is an active member of the antimicrobial stewardship program.

References:

1. The Joint Commission. Approved: new antimicrobial stewardship standard. (1, 3-4, 8)Jt Comm Perspect. 2016; 36(7).
2. Centers for Disease Control and Prevention. Core Elements of Hospital Antibiotic Stewardship Programs. Accessed October 18, 2019. https://www.cdc.gov/antibiotic-use/core-elements/hospital.html
3. Srinivasan A. Antibiotic stewardship grows up. Jt Comm J Qual Patient Saf. 2018;44(2):65-67.doi: 10.1016/j.jcjq.2017.11.002.
4. Meeker D, Linder JA, Fox CR, et al. Effect of behavioral interventions on inappropriate antibiotic prescribing among primary care practices: a randomized clinical trial. JAMA 2016;315(6):562-570. doi: 10.1001/jama.2016.0275.
5. Hallsworth M, Chadborn T, Sallis A, et al. Provision of social norm feedback to high prescribers of antibiotics in general practice: A pragmatic national randomised controlled trial. Lancet 2016;387(10029):1743-1752.doi: 10.1016/S0140-6736(16)00215-4.
6. Barlam TF, Cosgrove SE, Abbo LM, et al. Implementing an antibiotic stewardship program: Guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. Clin Infect Dis. 2016;62(10):e51-77. doi: 10.1093/cid/ciw118.
7. Kuntz JL, Polgreen PM. The importance of considering different healthcare settings when estimating the burden of Clostridium difficile. Clin Infect Dis. 2015;60:831—836. doi: 10.1093/cid/ciu955.
8. Johnson LS, Patel D, King EA, et al. Impact of microbiology cascade reporting an antibiotic de-escalation in cefazolin-susceptible Gram-negative bacteremia. Eur J Clin Microbiol Infect Dis. 2016;35(7):1151-7. doi: 10.1007/s10096-016-2645-5.
9. Coupat C, Pradier C, Degand N, et al. Selective reporting of antibiotic susceptibility data improves the appropriateness of intended antibiotic prescriptions in urinary tract infections: a case-vignette randomised study. Eur J Clin Microbiol Infect Dis. 2013;32:627—636.doi: 10.1007/s10096-012-1786-4.
10. Tan TY, McNulty C, Charlett A, et al. Laboratory antibiotic susceptibility reporting and antibiotic prescribing in general practice. J Antimicrob Chemother. 2003;51:379—384. doi: 1093/jac/dkg032
11. Musgrove MM, Kenney RM, Kendall RE, et al. Microbiology comment nudge improves pneumonia prescribing. Open Forum Infect Dis. 2018;5(7):ofy162. doi: 10.1093/ofid/ofy162
12. Bauer KA, Perez KK, Forrest GN, Goff DA. Review of rapid diagnostic tests used by antimicrobial stewardship programs. Clin Infect Dis. 2014;59(S3):S134-45 doi: 10.1093/cid/ciu547.
13. Lam SW, Bass SN. Advancing Infectious Diseases Diagnostic Testing and Applications to Antimicrobial Therapy in the ICU. J Pharm Pract. 2019;32(3):327-338. doi: 10.1177/0897190019831162.
14. Carver PL, Lin SW, DePestelDD, Newton DW. Impact of mecA gene testing and intervention by infectious disease clinical pharmacists on time to optimal antimicrobial therapy for Staphylococcus aureus bacteremia at a university hospital. J Clin Microbiol. 2008;46:2381-3. doi: 10.1128/JCM.00801-08.
15. Spellberg B. The New antibiotic mantra-"shorter is better". JAMA Intern Med. 2016;176(9):1254-5 doi: 10.1001/jamainternmed.2016.3646.
16. Spellberg B. The Maturing Antibiotic Mantra: "Shorter Is Still Better". J Hosp Med. 2018 May 1;13(5):361.362. doi: 10.12788/jhm.2904.
17. Vaughn VM, Flanders SA, Snyder A, et al. Excess antibiotic treatment duration and adverse events in patients hospitalized with pneumonia: A multihospital cohort study. Ann Intern Med. 2019;171(3):153-163. doi: 10.7326/M18-3640.
18. Chavada R, Davey J, O'Connor L, Tong D. 'Careful goodbye at the door': is there role for antimicrobial stewardship interventions for antimicrobial therapy prescribed on hospital discharge? BMC Infect Dis. 2018;18(1):225. doi: 10.1186/s12879-018-3147-0.
19. Dyer AP, Dodds Ashley E, Anderson DJ, Sarubbi C, Wrenn R, Hicks LA, Srinivasan A, Moehring RW. Total duration of antimicrobial therapy resulting from inpatient hospitalization. Infect Control Hosp Epidemiol. 2019;40(8):847-854. doi: 10.1017/ice.20118.
20. Jones JM, Leedahl ND, Losing A, Carson PJ, Leedahl DD. A pilot study for antimicrobial stewardship post-discharge: Avoiding pitfalls at the transitions of care. J Pharm Pract. 2018;31(2):140-144. doi: 10.1177/0897190017699775.
21. Gandhi TN, Vaughn VM, Petty LA, et al. The Michigan Hospital Medicine Safety Consortium: Improving Patient Care by Reducing Excessive Antibiotic Use in Patients Hospitalized with Community-Acquired Pneumonia. Presented at IDWeek 2019 October 2-6, 2019; Washington DC. Abstract 2893.
22. Vaughn, V. Teamwork! Collaboration and Antimicrobial Stewardship: Collaboration with Hospitalists. Presented at IDWeek 2019 October 2-6, 2019; Washington DC.
23. Morris AM, Rennert-May E, Dalton B, et al. Rationale and development of a business case for antimicrobial stewardship programs in acute care hospital settings. Antimicrob Resist Infect Control. 2018;7:104. doi: 10.1186/s13756-018-0396-z