Antimicrobial Stewardship

Introduction - Scope of the problem   Recommended interventions and tools Premier's solutions Guidelines and references  Stakeholders

Antimicrobial stewardship introduction - Scope of the problem

It has been recognized for nearly five decades that up to 50 percent of antimicrobial use is inappropriate. The consequences of inappropriate use include increased microbial resistance, toxicity, hospital lengths of stay, as well as increased costs to patients, hospitals and payors. Efforts to bring improved appropriate use and reduce resistance have come from many stakeholders,  including professional societies; government and accrediting organizations; pharmaceutical companies; and a number of state public and private initiatives. Most recently, Congress has proposed legislation addressing antimicrobial usage. The Strategies To Address Antimicrobial Resistance (or STAAR) Act will strengthen federal antimicrobial resistance surveillance, prevention and control, and research efforts as well as enhance the collection of critical information on the use of antibiotics in humans and animals.

The greatest success can be achieved with an institution-wide comprehensive antimicrobial management program that has a multidisciplinary approach and focuses on appropriate selection, dosing, route and duration of antimicrobial therapy.  

The goal of all these public and private initiatives is to challenge practitioners to re-evaluate their practices and implement institution-wide policies and procedures regarding appropriate antimicrobial utilization. Antimicrobial stewardship programs (ASPs) are the current standard for meeting these challenges. Such programs seek to optimize antimicrobial selection, dosing, timing and durations of therapy in order to reduce resistance, reduce toxicities and enhance patient outcomes. 

There are many resources for hospitals to use as guides for implementing new ASPs or enhancing existing ones. A brief overview of these recommended interventions is provided here with links to selected guidelines and references.

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Recommended interventions and solutions

FREE Continuing Education Course for Pharmacists-LIVE

The long-awaited antibiotic use/resistance course for pharmacists is live. Weighing-in on Antibiotic Resistance: Pharmacists Tip the Scale, highlights the importance in understanding antibiotic resistance, the latest trends in antibiotic resistance in the community, mechanisms of resistance, why antibiotics are often prescribed inappropriately, and how to promote the proper use of antibiotics within the community pharmacy setting.

Once completed, to evaluate the webinar, receive a certificate, and print a transcript of continuing pharmacy education (CPE) credit/contact hour, please go to http://www.cdc.gov/TCEOnline This course is activity number WB 1739.

 

Center for Disease Control and Prevention (CDC)

A major source of guidance for solutions is the CDC’s new Get Smart for Healthcare program to complement the existing Get Smart: Know When Antibiotics Work program. Get Smart for Healthcare focuses on improving antibiotic use in hospitals and nursing homes. The goal of the Get Smart for Healthcare program is to expand the implementation of interventions to improve antibiotic use in these facilities. Resources are made available on:

Core components of antimicrobial stewardship programs

• Prospective audit with intervention and feedback
  • Concurrent and direct education to prescribers at a patient-specific level on local resistance patterns, clinical literature, antimicrobial selection, dosing and duration of therapy.
  • Education has historically been performed by physicians or clinical pharmacists.
• Formulary restriction and pre-authorization, two optimal methods:
  • Closed formulary with a defined set of available agents.
  • Pre-authorization with prescriber justification.

Suggested supplemental components of
antimicrobial stewardship programs

• Education – education is essential but only marginally effective in the absence of complimentary clinical interventions.
• Multi-disciplinary teams – including physicians, pharmacists, infection control professionals and microbiologists.
• Guidelines and clinical pathways – evidence based practice guidelines incorporating local microbiology data.
• Antimicrobial order forms – requiring physician justification for antimicrobial utilization.
• De-escalation of therapy – utilizing the most narrow spectrum drug to treat a specific infection based upon culture results.
• Dose optimization – using patient specific criteria in conjunction with pathogen
  specific criteria to optimally dose antimicrobials.
• Computer surveillance and decision support – automating surveillance of antimicrobial utilization, resistance patterns and identification of hospital-acquired infection.
• Monitoring process and outcome measures – both are key elements to assessing the impact and outcomes of stewardship programs.

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Premier's solution for optimizing antimicrobial usage - SafetySurveillor™ - Pharmacy

• Premier's SafetySurveillor™ – Pharmacy is a web-based tool to assist clinicians and pharmacists with optimizing antimicrobial usage, enhance outcomes, and reduce the costs associated with inappropriate use.

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Guidelines and references

• IDSA-SHEA The Infectious Disease Society of America and the Society Healthcare Epidemiology of America Guidelines
  IDSA-SHEA Guidelines for Institutional Programs for Antimicrobial Stewardship Clinical Infectious Diseases. 2007;44(15 Jan):159-177
• CDC’s fact sheet
  CDC Fact Sheet on Appropriate Antimicrobial use for Hospitalized Patients.  
• SIDS recommendations
  Society of Infectious Diseases Pharmacist review and recommendations for implementing antimicrobial stewardship programs. Pharmacotherapy. 2004;24(7):896-908.
• Clinical microbiology review
  Comprehensive review of the rationale, structure and outcomes of antimicrobial stewardship programs in health-systems. McDougal et al. Clinical Microbiology Reviews. 2005;18:636-656.
• Automated surveillance tool for antimicrobial stewardship
  Impact of a computerized clinical decision support system on reducing inappropriate antimicrobial use: A randomized controlled trial. McGregor et al., Journal of American Medical Informatics Association. 2006;13:378-384.

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Stakeholders

Selected organization with resources and guidelines to support appropriate antimicrobial utilization.

Professional societies

APIC - Association for Professionals in Infection Control and Epidemiology

ASHP - American Society of Healthcare Pharmacists

IDSA - Infectious Disease Society of America

SHEA - Society for Healthcare Epidemiology of America

SIDP - Society of Infectious Disease Pharmacists

Premier Safety Institute - guidelines

• Guidelines
• Surveillance and antimicrobials

    Government agencies and accrediting organizations

CDC - Centers for Disease Control and Prevention

• Drug resistance
• Antimicrobial stewardship resources now available:

CMS - Centers for Medicare and Medicaid Services

TJC - The Joint Commission

   Congressional activity
    Strategies To Address Antimicrobial Resistance Act

Senate Version

House Version

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