Are Antibiotic Stewardship Programs Worth It?

Hospitals and other health-systems are seeing the benefits of instituting antibiotic stewardship programs. 

Blessing Health System didn’t need a recommendation from the CDC to initiate an antibiotic stewardship program (ASP). The Quincy, IL-based system had already put one in place in 2010, four years before the CDC presented its program designed to promote the appropriate use of antibiotics, slow down the development of resistance, and improve quality of care.

Blessing’s program first pulled clinical pharmacists on board by making sure they were certified in antimicrobial stewardship through the Society of Infectious Disease Pharmacists, to ensure consistency in training and continuity of care, says Andrea Chbeir, PharmD, Clinical Pharmacist Supervisor at Blessing. In 2015, the health system contracted with a community infectious disease physician, an on-call expert who makes rounds with the stewardship team.

Related article: What Makes a Successful Antibiotic Stewardship Program?

Initially, a pilot program focused on “drug/bug” mismatches based on patient-specific data to improve use.

The current program relies on decision support tools, real-time notifications, rapid diagnostics, and antibiogram data, based on facility-specific data that indicate an aggregate historical susceptibility of organisms to different antibiotics. These tools guide clinicians in determining which medications would be most effective for each patient. “We want to ensure we use the right antibiotic from the start,” Chbeir said.

“To prevent resistance, we take a narrow spectrum approach, in which medications target a specific bacteria without risking destruction of good bacteria in the body,” she said. If several antibiotics can be used to treat a small infection, the program ensures that the so-called “big guns” are reserved for infections that prove resistant to the majority of antimicrobials.

Since 2010, Blessing has seen a 20% reduction in drug resistance for certain drug/bug combinations and has made significant improvement in the appropriate use of antibiotics.

Preventing Inappropriate Use

Adam Sharp, MD, a researcher with the Kaiser Permanente Department of Research and Evaluation in California, led a study that showed that using computer alerts to inform doctors when antibiotics might not be the best course of treatment has reduced the odds of prescribing an antibiotic for sinusitis by 22%, as reported in the American Journal of Managed Care.¹

About 90% of patients with sinusitis are given a prescription for antibiotics even though current guidelines don’t recommend them for most patients. Sharp said it makes more sense to wait out sinusitis for two weeks before deciding to use an antibiotic.

Commitment, Consistency

Roy Boukidjian, MSN, PHN, System Director of Infection Prevention at San Francisco-based Dignity Health, said keys to the success of its ASP are commitment to start and consistency to finish.

The program has: modified electronic health record orders to require providers to establish why an antibiotic is being used; implemented antibiotic utilization ratio software for reporting lengths of therapy (DOT) and resistance patterns to the CDC for comparison against other hospitals; and created dashboards to reduce DOT system wide and metrics to measure DOT improvement. Dignity showed a 7% reduction in antibiotic usage in October compared to the first half of 2017.

Oversight, Education, Reminders

“We don’t always know the optimal way to find the right antibiotic to use with a specific disease, which can lead to over prescribing,” said Aaron Glatt, MD, Chair of Medicine at South Nassau Communities Hospital in New York and an epidemiologist. “When it isn’t clear, we have to rely on clinical judgment.”

Related article: Where Are the New Antibiotics?

The hospital put a stewardship program in place in 2013, which put clinical pharmacists specially trained in infectious disease on every floor, with access to infectious disease physicians. Glatt said the hospital has shown a decrease in overall use of antibiotics and a turn-around in inappropriate use.

“The responsibility falls on everybody, “Glatt said. “To have a successful program, you need oversight, education, physician reminders, and follow up.”

Despite efforts to reduce antibiotic resistance and overuse, statistics about prevention do not bode well. Even though an estimated 50% of antibiotics are prescribed inappropriately, only 40% of U.S. hospitals have an ASP, according to the CDC.