"Make Antibiotics Great Again:" A Reflection on Antibiotic Stewardship

On March 29, 2017, in the Opening Plenary at the 2017 Society for Healthcare Epidemiology of America (SHEA) Spring 2017 Conference, held in St. Louis, Missouri, Sara Cosgrove, MD, MS, current president of SHEA, associate hospital epidemiologist and professor of medicine at Johns Hopkins School of Medicine, discussed the new landscape of antibiotic stewardship (AS) with a room full of eager attendees. She highlighted where AS was in the past, where it is now, the pros and cons of new requirements, and a program that may achieve sustained improvement in antibiotic use.

Dr. Cosgrove started off the discussion by explaining how the goals for AS programs have changed over time. She said that when AS programs were first put into place, it seemed that the “driving force” behind them was to reduce cost when it came to antibiotics. Back in the 1990s and 2000s, there was only somewhat of a focus on reducing antibiotic resistance, and stewardship was not really thought of as a patient safety issue.

Now, however, the driving force behind these programs appears to have shifted. “I think we have changed a bit, and now there is a recognition that antibiotic stewardship is not just there to save money. I like to really believe that there has been a shift to antibiotic stewardship being there to optimize the safety of patients [receiving antibiotics]," explained Dr. Corsgrove, which means that if they do not need them anymore, healthcare providers stop prescribing them. Having a common vision dedicated to optimizing patient safety is “where we are now.”

Dr. Cosgrove shared that there are national requirements for antibiotic stewardship that are emerging across all healthcare settings. In fact, 48% of hospitals “have robust antibiotic stewardship programs as defined by the Centers for Disease Control and Prevention (CDC).” However, she also noted that when it comes to long-term care or ambulatory practices, there are not many that have organized AS activities, and although a national surveillance system for inpatient antibiotic use is currently in place, there is slow uptake.

When it comes to acute care, there is one requirement that calls for “antibiotic stewardship in hospitals and other settings,” and according to Dr. Cosgrove, and “this is a major driver moving forward.” So, what does the requirement look like? It takes the form of The Joint Commission (TJC)’s “Eight Elements of Performance,” which are as follows:

1. AS is an organizational priority
2. Educate staff about AR and AS
3. Educate patients/families about appropriate antibiotic use
4. Create an AS multidisciplinary team (ID physician, pharmacist, IP [infection preventionist], practitioner
5. Ensure Antibiotic Stewardship Programs (ASPs) include the CDC Core Elements
6. Utlize organization-approved multidisciplinary protocols
7. Collect/analyze/reports data on ASPs
8. Take action on improvement opportunities identified by ASPs

When it comes to the pros of these requirements, Dr. Cosgrove said, “I do think that there’s good synergy and alignment with the CDC Core Elements [and] societies, particularly SHEA and IDSA, and groups writing and enforcing the requirements (such TJC and Centers for Medicare and Medicaid Services, or CMS).” She added, “There are also many components of the requirements that are reasonable and actionable,” such as the requirement of having leadership support, having it fall under “Medication Management” rather than “Infection Control,” and the adequate emphasis on the importance of interventions, which “are the bread and butter of antibiotic stewardship.”

One of the biggest issues that Dr. Cosgrove noted with regards to the acute care requirements was that there is a notable lack of understanding when it comes to how the TJC will assess ASPs during survey. “There seems to be a focus on the patients that we do not usually touch in stewardship programs. In fact, it’s like, if you wanted to pick a group of patients in the hospital that the stewardship program is generally not involved with, it’s this list of patients that TJC says they are going to focus on during the survey.” said Dr. Cosgrove. These patients include “emergency department patients who are prescribed antimicrobials, ambulatory and clinic patients surveyed under the hospital program who are prescribed antimicrobials, [and] hospitalized patients who will be discharged on antimicrobials.”

Even though there were two elements of performance that focused on educating healthcare workers and patients, Dr. Cosgrove said that this education was “of uncertain value.” Since ASPs work on smaller budgets, and sometimes no funding at all, “they must optimize how time is spent.” She said, “I’m concerned that us running off and making education modules, and trying to deal with patients in the ambulatory clinic is really not where the focus of our program should be. We need to ensure that as we are compliant with TJC standard, that this is not superseding our ability to really do the interventions we need to do on the patients who are really affected by suboptimal antibiotic use.”

She also touched on the CMS requirements pertaining to long-term care, which is particularly important since there are 15,000 facilities and 1.5 million residents of these facilities who are reimbursed by CMS. The CMS infection control requirements for long-term care have been revised to require ASPs starting on November 28, 2017; this means that facilities are required to have an infection prevention and control program (IPCP) that includes ASP, which should include “antibiotic use protocols and systems for monitoring antibiotic use” as well as “recording incidents and corrective actions taken by the facility.” Furthermore, IPCPs should be led by an infection control and prevention officer, and a pharmacist “must review the resident’s medical record when performing the monthly drug regimen review when the patient is receiving an antibiotic.”

Dr. Cosgrove emphasized that she feels that the CMS requirements focus on the most important AS components: “providing guidance for use, and monitoring use.” The fact that they are based on the CDC Core Elements is also a plus. However, she did have some issues with the CMS requirements as well. For example, she felt that, according to the language used in the Federal Register, leadership responsibilities seem to be placed with an infection control and prevention officer. She commented, “I understand why this is, because they’re trying to put someone in charge…but we know from our experience in the inpatient setting that physician and pharmacist leadership is likely needed for sustained change in antibiotic use.”

She added, “We have to figure out how to balance the reality of these sources in long-term care with what is really needed to change prescribing practices, I think we need to be more innovative and I actually think we need to be more accepting of our role in long-term care as physicians because I think everyone rolls their eyes except for the brave few who actually do this. This is a public health issue. We need to involve ourselves in long-term care.”

When it comes to the future of antibiotic stewardship, the number of hospitals and long-term care facilities with ASPs is going to “dramatically increase” in the United States, according to Dr. Cosgrove. Although the requirements will not solve all of the problems that need to be addressed, staying on top of how these requirements are developed and applied is imperative.

In order to improve ASPs, a clear understanding of the “best practice in stewardship interventions in different settings” is needed. According to Dr. Cosgrove, it is also imperative to “expand the evidence base for optimal antibiotic use,” to “improve measurement of overall and appropriate antibiotic use” and to improve integration of efforts across all healthcare settings. She explained, “We tend to silo ourselves. We need to open that conversation a little bit more because we really need to improve this across the board, not just in an individual hospital or an individual setting.” Gaining better insight into prescribing behavior is also needed.

Dr. Cosgrove shared a little bit about the Agency for Healthcare Research and Quality, Safety Program for Improving Antibiotic Use, which is based off of a previous program called the Comprehensive Unit Based Safety Program, or CUSP. This program worked to reduce central line-associated bloodstream infections (CLABSI), catheter-associated urinary tract infections (CAUTI), and ventilator-associated events (VAE) through intervention. She explained, “The idea is that you make healthcare safer by improving the foundation of how physicians, pharmacists, nurses, and all other healthcare team members work together by combining the best clinical practices with the science of safety.” Dr. Cosgrove wants individuals to reflect on “the best way to prescribe antibiotics” in acute care, long-term care, and ambulatory care. She joked, “If we are alive to tell the results in four years, I’m hopeful that I will tell you that an adaptive approach to stewardship is a good thing.”

She concluded, “I think that there’re two pieces of the pie. First, we have to leverage and improve new requirements to develop and expand stewardship across the healthcare spectrum. Then, we have to work to modify behavior around antibiotic prescribing by addressing these adaptive concerns. And if we do that, I think we will see sustained improvement in antibiotic use, and then antibiotics will be great again!”

DISCLOSURES

Consulting: Novartis—infection adjudication committee; Theravance—infection adjudication committee

SOURCE

2017 SHEA Spring Conference

PRESENTATION

Opening Plenary: A Rapidly Changing Field