ASPs vs. microbial resistance: Pharmacists lead the charge

In the best of all possible worlds, an antibiotic would be prescribed only when it is known to be effective against the bacterial infection being treated. We don’t live in that world yet, but as more antibiotic stewardship programs (ASPs) are being created, at least we are heading that way.

The goal of ASPs is to slow the spread of microbial resistance through drug management as well as to minimize any harm to patients from inappropriate or unneeded antibiotic use. Federal health policy pushes for the creation of ASPs, but so far, they are in fewer than 40% of American hospitals. California is ahead on this issue; it now requires them in acute care hospitals.

The Pew Report

The Antibiotic Resistance Project of the Pew Charitable Trusts has evaluated ASPs to help determine how to improve antibiotic use in acute and long-term-care facilities. The nonprofit organization’s report, “A path to better antibiotic stewardship in inpatient settings,” looks at 10 case studies in hospitals across the country.¹

The report notes that up to 50% of all antibiotics prescribed in the United States, including many used in hospitals, were unneeded or used inappropriately. This inappropriate use gives rise to antibiotic-resistant organisms that cause more than 23,000 deaths each year and increase the risk of Clostridium difficile infections in healthcare settings.¹

Guidelines on ASPs from the CDC call for inclusion of seven elements: leadership commitment, accountability, drug expertise (with a pharmacist leading the effort to improve antibiotic use), action, education, tracking, and reporting.² The Infectious Diseases Society of America (IDSA) and the Society for Healthcare Epidemiology of America (SHEA) have issued joint recommendations, as well.

Three of the hospitals described in the report are Williamson Medical Center in Nashville, Tenn., St. Tammany Parish Hospital in Covington, La., and Strong Memorial Hospital in Rochester, N.Y.

Williamson Medical Center

Williamson Medical Center is a 185-bed hospital with an emergency room and a pharmacy staffed by 16 clinical staff pharmacists and a half-time internal medicine clinical pharmacist. Four physicians manage an infectious disease (ID) consultation service. Its ASP has been in place since 2009; before which there had been an open and unrestricted antibiotic formulary. The ID physician and the pharmacist developed a list of restricted or nonformulary antibiotics, with suggested substitutions. Since 2012, the ASP has been formalized as a subcommittee of the pharmacy and therapeutics committee.

The program uses IDSA/SHEA guidelines on antibiotic stewardship, tools from the Society of Infectious Diseases Pharmacists Certificate Program in Antimicrobial Stewardship, and the CDC Checklist of Core Elements. A clinical decision support system (CDSS) triggers alerts when an antibiotic has been ordered for more than three days, when a patient tests positive for C. difficile, or when a patient is shifted from intravenous to oral antibiotics.

Montgomery Williams“Our ASP has evolved to include more members of the pharmacy on the ASP committee: A critical care pharmacist, a pediatric pharmacist, and a clinical pharmacy manager,” said Montgomery Williams, PharmD, BCPS, the internal medicine and antibiotic stewardship pharmacist with Williamson and Belmont University College of Pharmacy in Nashville.

“I would encourage other programs that are beginning an ASP to start small. Identify a physician champion and select an initiative or project that can be implemented with minimal resources, such as a formulary review or MUE [medically unlikely edit],” she said.

Williamson’s ASP involves fourth-year pharmacy students. “This has been a great learning experience for the students in an interdisciplinary setting. Beyond patient care, they are also able to experience the administrative aspect of the program and help with data collection and projects as available,” Williams said.

At Williamson, the ASP has reduced the number of C. difficile cases from 26.3 per 10,000 patient days in 2012 and 2013 to 21.1 in 2014, and increased the susceptibility rates to levofloxacin of Pseudomonas aeruginosa from 58% in 2009 to 79% in 2014.

St. Tammany Parish Hospital

St. Tammany Parish Hospital (STPH) has 244 beds and includes a neonatal intensive care unit. There are three ID physicians on staff, and the pharmacy has a department head, an operations and information technology manager, two clinical pharmacists, and 11 staff pharmacists.

The hospital’s ASP originated with an ID physician who started a “Bug Club” after noticing a pattern of infections in coronary artery surgeries in the New Orleans area. The first members were ID physicians, infection preventionists, and clinical pharmacists from several area hospitals. When another hospital started an ASP and showed decreased antibiotic use, staffers at STPH were able to make the case for a similar program and obtain funding for a CDSS.

Jo Watkins“The most effective part of our program is real-time interventions,” said Jo W. Watkins, RPh, clinical coordinator at STPH. If you are running reports on a weekly basis, “you don’t get the bang for your buck,” she said. “Real-time, face-to-face discussion is where we got a major impact from the program.”

Having a physician who will go to bat for the program is important, and at STPH that was Dr. Michael Hill, Watkins added. “I cannot say enough on how important our physician champion was to the success of this program.” However, she also noted that STPH has a strong hospitalist group whose cooperation was another key to the program’s success.

STPH saw a decrease in the number of C. difficile cases from 9.6 cases per 10,000 patient days in the third quarter of 2013 to 6.4 cases per 10,000 patient days by the end of 2014. Total antimicrobial cost per adjusted patient-day was reduced from $25.93 in October 2012 to an average cost of $8.32 per patient-day after the program was implemented. Between July 2013 and December 2014, ASP review of antimicrobials has resulted in a total savings of $1.3 million.

Strong Memorial Hospital

Strong Memorial Hospital is an academic medical center associated with the University Rochester; it has more than 700 beds. Infectious disease care is provided through the University of Rochester’s ID division. One ID physician, one ID pharmacist, and one resident pharmacist provide service for the hospital’s ASP.

Strong’s ASP is nearly 20 years old. It started as an antibiotic management program focused on cost savings through drug restrictions. It later expanded into monitoring outpatient use of parenteral antibiotics and an emergency-department-based stewardship program.

Christopher Evans“There are a lot of different interventions that would qualify as antibiotic stewardship,” said Christopher Evans, PharmD, infectious disease pharmacist with the University of Rochester-Strong Memorial Hospital. “Choosing what works for your hospital may not be what everyone else has done. You have to figure what is needed and what you can do and what you can see results from. You are going to find one or two interventions that you can work on and then build up from there.”

Because of Strong’s ASP, antibiotic use in days of therapy per 1,000 patient-days and antibiotic cost per patient-day has remained low since the program was implemented. The ASP teams found that the electronic health record system and computerized physician order entry system can help guide therapy choices without the use of a CDSS.

In addition to its own ASP, Strong also participates in a collaborative ASP with other hospitals in the Rochester area. This regional ASP targets the high-risk antibiotics that increase the risk of C. difficile infections, Evans said.  

References

1. Pew Charitable Trusts. A path to better antibiotic stewardship in inpatient settings. April 2016. Available at www.pewtrusts.org/en/research-and-analysis/reports/2016/04/a-path-to-better-antibiotic-stewardship-in-inpatient-settings. Accessed May 2016.

2. Centers for Disease Control and Prevention. Core elements of hospital antibiotic stewardship programs. Available at www.cdc.gov/getsmart/healthcare/implementation/core-elements.html.