Despite some reductions in the overall antibiotic resistance problem, much more work needs to be done, according to a presenter at the 2019 Annual American Society of Health-System Pharmacists Midyear Clinical Meeting & Exposition.
Captain Arjun Srinivasan, MD, who is associate director for Healthcare-Associated Infection Prevention Programs with the Centers for Disease Control (CDC) began his talk by explaining that every year in the United States, 2.8 million people have an infection that resists first-line antibiotic treatment.
Dr. Srinivasan noted that although there has been progress in health care settings, over the past 5 years there have been important reductions in some areas, other organisms, like drug-resistant gonorrhea, present ongoing challenges.
He noted that the Centers for Medicare and Medicaid Services (CMS) has urged health systems, by March of 2020, to implement Infection Control and Antibiotic Stewardship programs for all acute care and critical access hospitals in the United States.
He noted that the CMS recommendations align with the 7 Core Elements of Antibiotic Stewardship outlined in 2014 by the CDC. Srinivasan said that the number of hospitals that self-report they have implemented all 7 elements of these stewardship recommendations has increased from 41% to 85%, and, he noted, every type of hospital from larger to smaller health systems have reported progress.
Dr. Srinivasan detailed a number of important enhancements under each Core Element heading, specifically:
- Hospital Leadership Commitment – Hospital leaders must ensure their facilities invest enough time, money, lab equipment and IT technology. Top executives are urged to meet with the stewardship team to understand what resources are necessary to meet antibiotic stewardship goals. Top leaders should be kept informed of progress.
- Accountability – There is a need for program management and outcomes that should be co-led by a physician and a pharmacist. Leadership requires collaboration and good communication skills. Dr. Srinivasan reported that 59% of current programs are currently co-led by a physician and a pharmacist, and he said, these programs are the model to follow.
- Pharmacy Expertise – This wording has been updated from the earlier recommended “Drug Expertise” to better reflect the role of pharmacists and showcase their vital importance this area, he said. Dr. Srinivasan added that most US hospitals don’t have access to infectious disease-trained pharmacists, so general clinical pharmacists need to be supported with education and resources.
- Action – This involves implementing the antibiotic interventions. The top two priorities Dr. Srinivasan noted were prospective audit and feedback, and reviewing therapy, where an expert gives providers feedback on antibiotic interventions. Providers are encouraged to seek preauthorization–currently only 41% do. They should also seek permission for certain restricted antibiotics. The third priority is to have facility-specific treatment guidelines. Srinivasan said focus was needed on 3 conditions that are most often prescribed antibiotics: lower respiratory infections, urinary tract infections, and skin and soft tissue infections. Providers are urged to follow treatment guidelines, optimize therapy length, have better urine culture practices, and narrow spectrum therapy for skin and soft tissue infections for antibiotic stewardship.
- Reporting – Facilities should report on use and resistance to prescribers, pharmacists, nurses, and hospital leadership regularly, and share information among different types of hospitals. Providers should compare reports with peers, and summaries should be regularly shared with leadership and hospital board, Dr. Srinivasan explained.
- Education – Teaching adverse reactions, resistance and optimal prescribing to prescribers, pharmacists, and nurses is a necessary aspect of stewardship. Srinivasan said case-based teaching is especially effective. Information should also be tailored to a specific provider group. In addition, providers need to better educate patients about judicious antibiotic use.
- Tracking – Prescription monitoring, intervention impact, and disease resistance patterns need to be tracked, Dr. Srinivasan said. Outcome measures, process measures of adherence to treatment guidelines and recommendations should be tracked and reported; hospitals report data to CDC’s National Healthcare Safety Network Antibiotic Use option to benchmark use.
Multiple measures are needed to ensure implementation, Dr. Srinivasan said. The use of the Standardized Antimicrobial Administration Ratio (SAAR), a ratio of actual use to predicted antibiotic use can facilitate tracking of antibiotic use.
“Predicted use is modeled based on all data submitted and is risk adjusted based on a variety of hospital characteristics, but not on any patient level factors,” Dr. Srinivasan said. SAARS was endorsed by the Quality Forum 2016 and can be used for different groups of antibiotics, adult and pediatric locations, ICU and non-ICU locations, and calculated at individual unit level or hospital wide.
Many facilities have rates of use greater than 1 (using more antibiotics than other hospitals). Dr. Srinivasan stressed that SAARS just records rates of use and not appropriateness. He pointed out that higher rates of use are a reason to investigate that particular location, and added that 25% of locations are using 20% more antibiotics worldwide. “This is a new metric and we are still trying to understand what the values mean,” he said.
A Path Forward
Changing prescriber behavior and “helping find the bright spots,” meaning, following behaviors that are effectively reducing unnecessary use of antibiotics are both key in reducing antibiotic resistance.
In outpatient settings, Dr. Srinivasan emphasized that providers can tell patients that avoiding unnecessary antibiotics can protect them. Educating patients can also help them avoid adverse drug reactions and avoid disruption of the microbiome, which can increase the risk of sepsis.
Read More: The Future of Pharmacy Chains
Dr. Srinivasan urged a collaborative process in creating stewardship programs because it provides partnership and solidarity between different providers. While the CMS is now urging antibiotic stewardship in all hospitals, it needs to be enforced to work, he said.
Dr. Srinivasan noted how bedside nurses play a critical role–because they administer antibiotics. They can prompt the provider and care team, and educate the patient and family, he said. He also emphasized the pharmacist’s role in helping with antibiotic stewardship: pharmacists can verify penicillin allergy, avoid duplicate anaerobic coverage, deescalate anti-MRSA coverage by confirming infection, avoid treatment of ASB, and limit antibiotic duration when symptoms improve.
According to Dr. Srinivasan, the CDC is urging judicious antibiotic use accreditation for urgent care centers. They are also working with the Health Services Resource Administration to reach out to federally qualified rural health care programs to improve antibiotic stewardship. CDC officials are also working with National Center for Quality Assurance to expand health Effectiveness Data information Set measures for outpatient prescribing.
Srinivasan A. CDC update 2019: Antibiotic stewardship in America’s hospitals [337-L04]. Presented at ASHP Midyear Clinical Meeting & Exposition. December 8, 2019. Las Vegas, Nevada.