Antibiotic Stewardship Programs in the Hospital Setting: Guidance from the Centers for Disease Control and Prevention

Now more than ever, Antibiotic Stewardship Programs (ASPs) are garnering attention throughout healthcare. It has been well documented that approximately 20-50% of all antibiotics prescribed in the hospital setting are unnecessary

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. While antibiotics serve a meaningful purpose in treating infections, appropriate use of these agents in order to minimize adverse events, including the development of C. difficile infection (CDI), and reduce the development of drug-resistant organisms is vital.

In 2014, the Centers for Disease Control and Prevention (CDC) recommended the implementation of ASPs for acute care hospitals and published a document highlighting the recommend core elements for these programs

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. These elements include:

Leadership Commitment:

This is critical to ensure the success of ASPs. Programs may consider including formal statements at their facility supporting efforts to improve antibiotic use. There should be participation from various groups across the institution to further the program’s activities. Additionally, financial support from hospital administration should be present to ensure necessary resources for the success of the ASP are available.

Accountability & Drug Expertise:

Accountability for ASP outcomes is recommended in the form of a single leader (i.e., physician champion). Additionally, a pharmacy leader should be identified to co-lead the program. Formal training in infectious diseases and/or antibiotic stewardship benefits program leaders. Other key personnel who should be targeted for engagement in ASPs and activities include:

• Clinicians and department heads
• Infection preventionists and hospital epidemiologists, who can coordinate facility-wide monitoring and prevention of healthcare-associated infections
• Laboratory staff can guide proper use of tests and the flow of results. They can also guide empiric therapy by creating and interpreting a facility’s antibiogram.
• Information technology staff, whose collaboration is important to improve workflow for ASP team members and provider assistance with development of clinical decision support tools.

Action:

ASPs should implement policies supporting optimal antibiotic use and avoid addressing too many interventions simultaneously. Interventions should be prioritized based on the hospital’s needs and availability of resources / content expertise.

CDC’s guidance breaks down actionable interventions into three types: broad, pharmacy-driven, and infection/syndrome specific interventions. Examples of broad interventions include antibiotic “time outs”, prior authorization, and prospective audit and feedback. Antibiotic “time outs” prompt a reassessment of continued need and choice of initial empiric antibiotics, usually when more diagnostic information is available. Some facilities may choose interventions focusing on prior authorization strategies, where antibiotic restriction is done to ensure use is reviewed with an antibiotic expert before therapy is initiated. Alternatively, prospective audit and feedback may be utilized by other ASPs, allowing for direct interaction with the provider after initial ordering and dispensing of the agent is complete.

Pharmacy-driven interventions focus directly on interventions made by pharmacy staff and come in various forms. Automatic changes from intravenous to oral therapy can be performed in appropriate situations and for antibiotics with good absorption in order to improve patient safety and reduce the need for intravenous access. Dose optimization, including modifications based on therapeutic drug monitoring and organ function, allows for adjustments in antibiotics based on pharmacokinetic and pharmacodynamics considerations of the drug. Pharmacists can respond to alerts for situations where duplicate therapy might be unnecessary, such as simultaneous use of multiple agents with overlapping spectra. ASPs may implement time-sensitive automatic stop orders for specified scenarios, especially for surgical prophylaxis. Finally, detection and prevention of antibiotic-related drug-drug interactions may be considered, including interactions between orally administered fluoroquinolones and certain vitamins.

Infection and syndrome specific interventions are intended to improve prescribing for specific syndromes; however, these should not interfere with prompt and effective treatment for severe infections or sepsis. Some examples include community-acquired pneumonia, urinary tract infections, skin and soft tissue infections, empiric coverage of methicillin-resistant Staphylococcus aureus (MRSA), and CDI. In these situations, optimizing the agent of use, dosing, and duration of therapy are imperative. Local resistance patterns and national guidelines will assist ASPs to implement these recommendations at their institution. When considering CDI, these infections can be a direct result of antibiotic use and should be a large focus for ASPs. Reviewing antibiotics in patients with new diagnoses of CDI can identify opportunities to discontinue unnecessary antibiotics.

Tracking & Reporting:

Measurement of antibiotic prescribing is critical to identify opportunities for improvement and assess the impact of a programs efforts. For ASPs, this may involve evaluation of both process and outcome. ASPs should perform periodic assessments of the use of antibiotics or treatment of infections to determine the quality of antibiotic use. Standardized tools, such as drug use evaluations or antibiotic audit forms, can assist in these reviews.

Measurement of antibiotic use may be done through days of therapy (DOT) or defined daily dose (DDD). Compared to DOT, DDD estimates are not appropriate for children, are problematic for patients with reduced drug excretion (i.e., renal impairment), and are less accurate for between-facility benchmarking. However, DDDs can be a useful measure of progress when tracked using a consistent methodology over time. Finally, ASPs should track clinical outcomes measuring the impact of interventions to improve antibiotic use. Improving antibiotic use has a significant impact on rates of hospital onset CDI. Reducing antibiotic resistance should be another important goal of efforts to improve antibiotic use.

Education:

ASPs should provide regular updates on antibiotic prescribing, resistance trends, and infectious disease management addressing national and local issues.facility-specific information on antibiotic use to be available for staff members can motivate improvements in prescribing patterns. Education may include didactic presentations, messaging through flyers and newsletters or electronic communication to staff groups. Education has been found to be most effective when paired with corresponding interventions and measurement of outcomes⁵.

ASPs should use these elements as guidance at their individual institution. CDC’s guidance document also includes a checklist that ASPs can use to assess the current state of their program. Advancements in antibiotic stewardship continue to grow, including rapid diagnostic testing technology in the laboratory. We should all expect to hear more on the value of ASPs and best practice elements in the coming months and years.

Dr. Zeitler received her Bachelor of Science degree in Chemistry from Fairfield University, CT in 2007 followed by her Doctor of Pharmacy degree from the University at Buffalo, NY

in 2011. For post-graduate residency training, she completed both a pharmacy practice residency and Infectious Diseases Specialty Residency at the Hospital of the University of Pennsylvania (Philadelphia, PA). She joined Tampa General Hospital (Tampa, FL) in 2013 to further develop and grow the Antimicrobial Stewardship Program (ASP). Her current practice includes supporting stewardship services throughout the hospital, collaborating with ID and non-ID services, and providing education related to ID and ASP. She also serves as a co-chair of the Tampa General Hospital Antimicrobial Subcommittee. Dr. Zeitler is a current member of ASHP, ACCP and SIDP.

References:

1. CDC. Core Elements of Hospital Antibiotic Stewardship Programs. Atlanta, GA: US Department of Health and Human Services, CDC; 2014. Available at http://www.cdc.gov/getsmart/healthcare/implementation/core-elements.html. Accessed 4 August 2016.
2. Camins BC, King MD, Wells JB, et al. Impact of an antimicrobial utilization program on antimicrobial use at a large teaching hospital: a randomized controlled trial. Infection Control and Hospital Epidemiology. 2009; 30 (10): 931—938.
3. Ingram PR, Seet JM, Budgeon CA, Murray R. Point-prevalence study of inappropriate antibiotic use at a tertiary Australian hospital. Internal Medicine Journal. 2012; 42 (6): 719—721.
4. Fridkin SK, Baggs J, Fagan R, et al. Vital Signs: Improving Antibiotic Use Among Hospitalized Patients. MMWR. Morbidity and Mortality Weekly Report. 2014; 63.
5. Dellit TH, Owens RC, McGowan JE, Jr., et al. Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an Institutional program to enhance antimicrobial stewardship. Clinical Infectious Diseases. 2007; 44 (2): 159—177.