The nuts and bolts of antibiotic stewardship programs
Continuing Education Objectives
After reading this article, you will be able to:
- Discuss the need for antibiotic stewardship programs
- Identify the core elements of hospital antibiotic stewardship programs
- Explain optimal antibiotic use policies
Editor's note: Elizabeth DiGiacomo-Geffers, RN, MPH, CSHA, is a healthcare consultant in Trabuco Canyon, California, and a former Joint Commission surveyor.
The creation and expanded use of antibiotics has allowed for the successful treatment of routine infections and safer surgical procedures. However, there has also been overuse and, in some cases, misuse of antibiotics. This has led to the rise of antibiotic-resistant infections, making antibiotics less and less effective.
Last month, the White House convened a special forum on antibiotic stewardship attended by more than 150 healthcare organizations, including the Centers for Disease Control and Prevention (CDC) and The Joint Commission, and announced increased efforts to promote effective antibiotic stewardship within healthcare facilities.
There is growing evidence that hospital-based programs dedicated to improving antibiotic use, referred to as antibiotic stewardship programs (ASP), can strengthen treatment as well as reduce antibiotic-related adverse events, according to a report issued by the CDC last fall. The report, Core Elements of Hospital Antibiotic Stewardship Programs, highlights the needed components for a successful stewardship program.
Core elements of ASPs
The elements discussed in this article are designed to complement existing guidelines from organizations such as the Infectious Diseases Society of America and The Joint Commission. There isn't a "one size fits all" approach to optimize antibiotic prescribing in hospitals. Hospitals will need to determine what works best for them given their resources and financial capabilities.
Not surprisingly, leadership commitment is key to the success of stewardship programs, according to the CDC report. Leadership can show support in a number of ways, such as:
- Issue formal statements supporting efforts to improve and monitor antibiotic use
- Include stewardship-related duties in job descriptions and performance reviews
- Ensure staff has enough time to contribute to activities
- Ensure participation from hospital groups that can support stewardship activities
Accountability and drug expertise
The leadership of the stewardship program should include someone, such as a physician, who is responsible for the program outcomes. There should also be a pharmacy leader who will colead the program. Both leaders should have training in infectious diseases and/or antibiotic stewardship from either the CDC or other formal organizations.
The stewardship committee should be a multidisciplinary committee composed of members of key hospital groups.
Actions that support optimal antibiotic use
Hospitals will need to create and put in place policies that support optimal antibiotic use, such as documenting dose, duration, and indication. This ensures that antibiotics can be easily identified, modified as needed, and/or discontinued.
Additionally, develop and implement facility-specific treatment recommendations based on national and state guidelines. This will help optimize antibiotic selection and duration, particularly for common usage scenarios like community-acquired pneumonia, intra-abdominal infections, urinary tract infections, and skin and soft tissue infections.
Interventions to improve antibiotic use
The aim of the interventions is to improve antibiotic use and increase quality of care. Interventions should be divided into three categories: broad, pharmacy-driven, and infection- and syndrome-specific.
Broad interventions encourage the use of antibiotic timeouts, prior authorization, and drug-related audit and feedback. The use of an antibiotic timeout 48 hours after the initial order reminds the physician to revaluate the order to determine the continuing need for the drug and whether the correct antibiotic was initially chosen.
Prior authorization by an antibiotic expert is required some antibiotics whose use may be restricted by spectrum of activity, cost, or other associated issues. Pre-authorization of the therapy needs to be completed in an appropriate time frame.
Prospective audit and feedback differs from the antibiotic timeout in that staff other than the treating team reviews the antibiotic therapy to ensure its effectiveness. This intervention has proven effective in the treatment of critically ill patients.
Pharmacy-driven interventions may include automatic changes from intravenous to oral antibiotic therapy in appropriate situations, which improves patient safety if there is no longer a need for intravenous access. Other pharmacy interventions include:
- Dose adjustments and optimization
- Time-sensitive auto stop orders
- Prevention/detection of antibiotic-related drug-drug interactions
Infection- and syndrome-specific interventions discuss treatment for specific syndromes, but should not interfere or preclude treatment for severe infection or sepsis. Recommended interventions for select issues include:
- Community-acquired pneumonia?focus on correcting recognized problems in therapy, including improving diagnostic accuracy and tailoring the therapy to culture results.
- Urinary tract infections?focus on avoiding unnecessary urine cultures; ensure patients receive appropriate therapy for the recommended duration.
- Empiric coverage of methicillin-resistant Staphylococcus aureus (MRSA) infections?stop therapy if patient doesn't have MRSA or change to beta-lactam if the cause is methicillin-sensitive Staphylococcus aureus.
- Clostridium difficile infections?review antibiotics in newly diagnosed patients to identify possible use of unnecessary antibiotics.
Tracking and reporting
A successful stewardship program should measure both the evaluation of the process as well as the outcome to determine any opportunities for improvement when administering antibiotics, according to the CDC.
The committee should ask questions that range from determining if policies are being followed as expected to evaluating whether the interventions put in place have improved antibiotic use and patient outcomes.
ASP committees should share regular updates on antibiotic prescribing, resistances, and infectious disease management at both the national and state levels with the healthcare organization. Sharing this information on a routine basis promotes improved prescribing and increased patient safety.
For the full list of references visit Accreditation & Quality Advisor at http://blogs.hcpro.com/acc/.
Core elements of hospital antibiotic stewardship programs
- Leadership commitment
- Drug expertise
Source: CDC. Core Elements of Hospital Antibiotic Stewardship Programs. Atlanta, GA: US Department of Health and Human Services, 2014 (www.cdc.gov/getsmart/healthcare/implementation/core-elements.html).