Curbing Antimicrobial Resistance
Antibiotic resistance caused by the overuse, misuse, and incorrect choice of antimicrobials in healthcare settings is a major threat to patient safety and outcomes. In September 2019, the Centers for Disease Control and Prevention (CDC) finalized new regulations requiring US hospitals to establish mandatory antimicrobial stewardship programs (ASPs) with the aims of curtailing the inappropriate use of antibiotics, controlling the risks of hospital acquired infections, and reducing the development and transmission of antibiotic-resistant organism organisms.1 Effective January 2020, all Joint Commission-accredited acute care settings are now also required to have antimicrobial stewardship plans in place, putting an even greater spotlight on the need for hospitals to meet quality and safety standards for the management of antibiotics.2
It Takes a Team
Numerous studies have estimated that between 25% and 50% of antibiotic use in hospitals is unnecessary or ineffective, leading to increased lengths of stay, Clostridium difficile infection, rates of resistant infections, and costs.3 A well designed ASP, therefore, is intended to reduce antibiotic days of therapy, length of therapy, and associated antibiotic expense.1
According to the CDC, the Core Elements of such an ASP should include a commitment from hospital leadership to provide adequate resources to operate programs effectively, accountability for program outcomes from physician and pharmacist co-leadership, pharmacy expertise to improve antibiotic use, and prospective audit and feedback that allows the ASP to interact directly with prescribers to tailor specific antibiotic therapy for each patient.1 The elements also include tracking and reporting of antibiotic prescribing and resistance patterns, as well as case-based education for prescribers, pharmacists, and nurses.1
Recent studies of various ASP programs across the country provide insights into how ASPs are aligning with the CDC’s core elements. One recent survey found that measures of ASP effectiveness are most closely correlated with adequate full-time physician and pharmacist involvement on multidisciplinary teams, including leading antibiotic decision-making.4
Integration of Technology
The role of information technology, including technology add-ons that can help ASPs with clinical decision-making, was also identified as an unmet need in assisting clinicians in timely and effective treatment interventions.4 Yet, many hospitals reported difficulties in the optimal use of data analytics due to limited resources and interoperability issues.4 The need for greater integration of technology to enable improvements in ASPs is often coupled with also improvements in identifying and intervening in the early signs of patient deterioration. This is particularly relevant on general hospital wards where rates of sepsis mortality approach 40 percent—and digital screening tools and prompts may not be as effective or widespread as in critical care settings.5 Therefore, the application of technologies that help integrate clinically relevant patient data in a way that helps clinicians in both early identification of patient deterioration and in cases where antibiotics are considered, could help provide better tools for treatment management will, in turn, improve the hospitals ASP.
Antibiotic Stewardship in Sepsis
Only about 30–40% of patients who are suspected of having an infection will actually have a positive microbiological diagnosis, yet still receive antibiotics, potentially resulting in unnecessary therapy .4,8 This is largely due to difficulty in determining whether or not a patient has an infection and if they do, it’s not easy to determine if they have sepsis. Sepsis can be difficult to diagnose in critically ill patients, particularly since inflammation and organ dysfunction can be present in many conditions other than infection.7 Once sepsis is diagnosed, the Surviving Sepsis Campaign’s (SSC) most recent “Hour-One Bundle” includes immediate steps to be initiated.6 Therefore, tools are needed to help improve the diagnosis of sepsis, ensure bundle compliance once diagnosed, manage antibiotic therapy which relies on having an effective ASP in place.
Identify, Intervene, and Tailor Therapy
When a sepsis bundle is triggered, prompt empiric therapy with a broad-spectrum antibiotic is the primary intervention.8 At the same time, good antibiotic stewardship calls for preliminary blood work and other testing prior to the administration of the empiric antibiotic to ensure that the specific antibiotic therapy is tailored to the patient.1,8 Not only is this critical in order to determine the “right antibiotic, at the right dose, for the right duration”, it prevents the clinician from overusing an empiric therapy once the etiology of the infection is determined.1 Local antimicrobial resistance data should also be as part of good antibiotic stewardship when an initial empirical antibiotic regimen is started. An expert review of the antibiotic therapy after an agent has been prescribed, including suggestions for optimizing use, is also considered a “foundational intervention” in an effective ASP. 1
Advancing Decision-Making in Antimicrobial Stewardship
Other best practices aligned with the CDC’s Core elements that can assist the ASP team in optimal clinical decision-making and antibiotic prescribing in both sepsis and other infections include:
- Integration and standardization of digital prompts and data analytics in identifying patient deterioration.5
- Information technology add-ons that provide clinical decision-making support tools. 4
- Access to rapid diagnostics in microbiology to ensure patients are receiving the right antibiotic tailored to their specific needs.1,8
In summary, empowering clinicians to use evidence-based, thoughtful, and informed approaches to antibiotic prescribing and management improves clinical outcomes and reduces adverse events and microbial resistance.
1. The Core Elements of Hospital Antibiotic Stewardship Programs: 2019, Centers for Disease Control and Prevention, US Department of Health and Human Services 2019. https://www.cdc.gov/antibiotic-use/healthcare/pdfs/hospital-core-elements-H.pdf Accessed January 2, 2020.
2. New, Revised Antimicrobial Stewardship Requirements for Ambulatory Health Care Organizations Introduced, News Release, The Joint Commission, June 2019. https://www.jointcommission.org/en/resources/news-and-multimedia/news/2019/06/new-revised-antimicrobial-stewardship-requirements-for-ambulatory-health-care-organizations-introduc/Accessed January 2, 2020.
3. The Expanding Role of Antimicrobial Stewardship Programs in Hospitals in the United States: Lessons Learned from a Multisite Qualitative Study, The Joint Commission Journal on Quality and Patient Safety, February 2018. https://www.ncbi.nlm.nih.gov/pubmed/29389462Accessed January 2, 2020
4. Essential Resources and Strategies for Antibiotic Stewardship Programs in the Acute Care Setting, Clinical Infectious Diseases, March 2018. https://www.researchgate.net/publication/324089755_Essential_Resources_and_Strategies_for_Antibiotic_Stewardship_Programs_in_the_Acute_Care_SettingAccessed January 3, 2020
5. Identifying Patients with Sepsis On The Hospital Wards, Chest, June 2017, https://psnet.ahrq.gov/issue/identifying-patients-sepsis-hospital-wards Accessed January 4, 2020.
6. The Surviving Sepsis Campaign Bundle: 2018 Update, Copyright © 2018 by the Society of Critical Care Medicine and the European Society of Intensive Medicine. http://www.survivingsepsis.org/SiteCollectionDocuments/Surviving-Sepsis-Campaign-Hour-1-Bundle-2018.pdfAccessed January 4, 2020
7. The New “Hour-One” Sepsis Bundle: Key Takeaways and Controversies, Nursing Center, June 2018. https://www.nursingcenter.com/ncblog/june-2018/hour-one-sepsis-bundleAccessed January 4, 2020
8. Diagnosis and Management of Sepsis, Clinical Medicine 2018. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6303466/pdf/clinmed-18-2-146.pdfAccessed January 4, 2020