Antibiotic Stewardship Program Implementation Reduces Antibiotic Use

A webinar series developed as a way to implement an antibiotic stewardship program was successful in improving key components of antibiotic stewardship as well as decreasing Clostridioides difficile (C diff) and other infections, according to a paper published in JAMA Network Open.

Investigators from Johns Hopkins Medicine and NORC at the University of Chicago evaluated their program over a 1-year period across 402 hospitals in the United States in order to determine the relationship between the use of the program and a reduction in antibiotic use in the country. A total of 28 academic centers, 122 mid-level teaching hospitals, 167 community hospitals and 85 critical access hospitals were involved in the study, of which about a third were rural hospitals. The authors explained that the safety program, called the AHRQ Safety Program for Improving Antibiotic Use, was aimed at best practices for antibiotic stewardship.

During the study period, there were 17 broadcast webinars lead by the investigators that were repeated 3 times and recorded for hospital participants. The leaders described antibiotic decision-making framework, posing questions to prescribers such as:

• Does the patient have an infection that requires antibiotics?
• Have the appropriate cultures been ordered prior to antibiotic initiation? What empiric therapy should be initiated?
• When is the right time to stop antibiotics, narrow therapy, or change from intravenous to oral therapies?
• What is the appropriate duration for antibiotic therapy?

These questions, the study authors said, can point clinicians to the correct times to review therapy plans, discontinuing, narrowing or transitioning treatment, and selecting the safest but most effective treatment durations.

To integrate these questions into daily practice, the toolkit guide offered suggestions, including:

• Incorporating local guidelines into the questions.
• Create posters and screen savers with reproducable graphics to remind clinicians of the key components of the program
• Direct interactions between the clinicians, teams, and antibiotic stewardship programs that will offer understanding of the purpose, and help determined how the program is implemented on a daily basis
• Developing a culture of safety around antibiotic prescribing, that includes the understanding that antibiotic use is a patient safety issue
• One-sheeters and forms describing how to identify antibiotic-associated adverse events and what to learn from these adverse events can be distributed and implemented

The antibiotic stewardship program could also include the aforementioned materials being presented in a group setting, such as standing monthly meetings, conferences, or topic-specific presentations or distributing the materials on a website, in a break room or at common work stations. The study toolkit also recommends regular follow up with stewardship program staff for review.

At the start of the program, the investigators learned that 43 percent of the hospitals did not have access to an infectious disease specialist and just 8 percent of hospitals reported adherence to all 4 key antibiotic stewardship program components. Adherence increased to 74 percent by the end of the observation period, the authors reported. The facilities that were actively engaged in the safety program were more likely to see a decrease in antibiotic use compared to those who displayed low engagement, the study authors said.

The investigators observed the largest decrease of bimonthly antibiotic use between Jan/Feb and March/April, and the decrease was sustained for the remainder of the observation period. The use of fluoroquinolone decreased from 105 to 84 days of antibiotic therapy (DOT) per 1,000 patient days across all units from the beginning to the end of the study period, the authors also noted.

During the study period, the study authors observed the number of hospital-onset C diff events per 10,000 patient days in quarter 1 to be 6.3, which dropped to 5.3 in quarter 2, followed by 6.0 in quarter 3 and 5.1 in quarter 4. This represents an overall decrease between the start and end of the observation period of almost 20 percent, the study authors wrote.

“These results are particularly remarkable as a large proportion of the hospitals in the study were under-resourced and did not have access to infectious disease specialists,” study author Sara Cosgrove, MD, MS said “They show that no matter their size, all hospitals can develop, establish and conduct good stewardship practices with the proper resources—and remind us of the importance of organized strategies to assist hospitals and clinicians in implementing medical care best practices.”