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7/13/2016

Smaller Size No Barrier to Effective Antimicrobial Stewardship

Kate Traynor

Kate TraynorNews Writer
News Center

Pharmacists are proving that it's possible to operate a robust antimicrobial stewardship program (ASP) that improves patient outcomes whether the facility serves a few dozen inpatients or a few hundred.

Two of the key elements of success for ASPs are the enthusiasm of the facility's staff and strong support from administrators, said Montgomery Williams, internal medicine and antibiotic stewardship pharmacist at Williamson Medical Center, a 185-bed community hospital in Franklin, Tennessee.

"We've been able to make such a big impact because of identifying the right people who are passionate about it—who understand why it's necessary and what an impact we can make," Williams said. "Having an infectious disease physician who really is passionate about the cause and also feels a pharmacist is vital to that antimicrobial stewardship program can really go a long way."

Montgomery Williams

Stewardship activities for clinical pharmacists at the hospital include performing prospective chart reviews to identify patients who are treated with antimicrobials, making automatic renal function–based dosage adjustments for about a dozen antimicrobials, and determining appropriate dosages for all orders for aminoglycosides and vancomycin.

Williams said the ASP itself has grown from an informal group to a structured enterprise that touches many areas of the hospital and has administrative backing to help coordinate the use of hospital staff and resources.

"Having their buy-in and their instruction has really just made a huge impact on what we're able to do and the time in which we're able to turn a lot of our initiatives around and get things implemented," Williams said.

Notable outcomes from the hospital's ASP include improvements in the susceptibility of Pseudomonas aeruginosa isolates to fluoroquinolones and other antimicrobials and a decrease in overall spending on antimicrobials.

"The antimicrobial cost per adjusted patient-day went from $15.64 in 2012–2013 to $14.12 in 2013–2014," Williams said. "We realize it's a pretty poor measure of outcomes, because cost fluctuates. But we are not yet able to evaluate drug utilization with days of therapy or defined daily dose. We're working on our clinical decision support system to be able to do that for us."

At Blessing Health System in Quincy, Illinois, one focus of the ASP—automating i.v.-to-oral antimicrobial conversions for appropriate patients—produces about $6000 in savings on drug costs each month, said Andrea Chbeir, clinical pharmacist supervisor at the 342-bed medical center.

Chbeir said the conversion project was undertaken to eliminate the need for pharmacists to leave written notes for prescribers about making the switches for individual patients and repeatedly checking on the status of those requests.

"It was really about efficiency," Chbeir said.

Andrea Chbeir

The stewardship program has also resulted in important changes in the hospital's antibiogram, she said. For example, the rate of susceptibility of P. aeruginosa isolates to levofloxacin, gentamicin, and piperacillin–tazobactam has increased by 13–18 percentage points since the ASP activities began. And the hospital has also seen a decrease in vancomycin-resistance rates among Staphylococcus aureus isolates and in increase in the appropriate use of linezolid.

At Sharp Coronado Hospital's Villa Coronado Skilled Nursing Facility in Coronado, California, reducing the rate of Clostridium difficile infection has been a major focus of stewardship activities, said Bridget Olson, infectious diseases (ID) and ASP pharmacist.

The 59-bed hospital is located across the street from the nursing facility, which has 60 skilled-care beds and 60 subacute care beds. Olson said the hospital launched an ASP program five or six years ago and then expanded it to Villa Coronado.

Bridget Olson

"It takes a while to build rapport with physicians and develop a stewardship culture where everybody's more aware of why they're using antibiotics and what the goals are with antibiotic stewardship," Olson said.

To address the C. difficile problem, Olson said, Villa Coronado's staff reduced and better targeted the use of antimicrobials, switched all patients who were taking a proton pump inhibitor for acid suppression prophylaxis to a histamine H2-receptor antagonist, and promoted the use of probiotics in patients taking antimicrobial therapy.

"And [by] doing those three things, our C. diff rate went down by 80%," Olson said. Data on this project were published last September in the Journal of Clinical Outcomes Management and showed that, on average, C. difficile infection rates had decreased over two years from 6.1 to 1.1 cases per 10,000 patient-days.

Olson said one of the first things the stewardship group did was to run microbiology reports on organisms that were infecting patients at the nursing facility. That information, along with antimicrobial sensitivity data, was used to determine the best empirical therapy for population-level control of those microorganisms.

To get a buy-in from the Villa Coronado staff, Olson and the hospital's ID specialist presented the antibiogram data during a "grand rounds" session about antimicrobial resistance patterns at the facility.

"The physicians basically didn't know all the dangers about resistance formation and what you could do with antibiotic stewardship," Olson said. "So after that they were a lot more onboard with what we were trying to do."

Olson said it's hard to determine when antimicrobial therapy is appropriate in nursing facility patients because many are asymptomatically colonized by bacteria and fevers of unknown origin are common in the elderly.

So the ASP team developed patient assessment forms based on the "McGeer criteria," a surveillance tool for identifying infections in nursing facility patients, and taught the facility's nursing staff how to evaluate when it's appropriate to request an antimicrobial.

"Now, when the physician gets called about a fever, he knows that the patient's already met criteria," Olson said. "We now avoid a lot of calls to physicians, which they really like. We've avoided transfers to acute [care]. And we've avoided a lot of unnecessary courses of antibiotics."

Chbeir said improvements in antimicrobial use at Blessing Health System are partly a result of the enthusiasm of a clinical pharmacy team that, until a few years ago, was "champing at the bit to break out and do great things" but lacked a clearly defined role at the hospital.

To modernize the pharmacy services, Chbeir said, the department developed a long-term plan that was aligned with the hospital's overall strategic goals and included objectives that could likely be accomplished with available resources.

She said the establishment of an active ASP was aligned with the hospital's overall objectives, but the program faced challenges, including the lack of a residency-trained ID pharmacist, an ID-specialist physician, and dedicated funding for stewardship.

"But we had motivated people," Chbeir said. "We had an epidemiologist. I recruited microbiology. I recruited a family medicine physician who had an interest in infectious diseases who had functioned as a hospitalist to be our physician champion. And I had six years of experience with antimicrobial stewardship and infectious diseases."

Chbeir said one potential barrier the ASP needed to overcome was the clinical pharmacists' lack of formal training in stewardship. Because the pharmacy department has a hybrid practice model, she said, every pharmacist has at least some involvement in reviewing orders for antimicrobials.

So Chbeir applied for and was awarded a grant from the hospital's foundation to allow all of the inpatient pharmacists to complete the certificate program in antimicrobial stewardship offered by the Society of Infectious Diseases Pharmacists. Pharmacists who participate in Blessing Health System's postgraduate year 1 residency program are also required to complete the certificate program and participate in stewardship activities at the hospital.

Olson said her ASP team similarly gets much-needed support from pharmacy students who come to the hospital and the nursing facility for experiential training in the management of infectious diseases.

"We use those students to look up all the labs and cultures every day, because that's very time intensive. Then they learn the practical application of antibiotics, which helps them," Olson said. "We're able to do a lot more education too because I have them work on different infectious disease cases to teach the other pharmacists. So that helps maintain the program," Olson said.

The stewardship programs described by Olson, Chbeir, and Williams were among 10 featured in an April 2016 report published by the Pew Charitable Trusts on improving antimicrobial use in inpatient settings. That report, part of Pew's antibiotic resistance project, is available online (www.pewtrusts.org/en/research-and-analysis/reports/2016/04/a-path-to-better-antibiotic-stewardship-in-inpatient-settings).

[This news story appears in the August 1, 2016, issue of AJHP.]

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