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Pharmacists are urged to adopt protocols to combat the constant rise of antibiotic resistance.
As pharmacists continually build their scope of expertise, hospital anti-microbial stewardship programs (ASPs) are just one more avenue for putting their experience and knowledge to work.
Anna Legreid Dopp, PharmD, director of clinical guidelines and quality improvement at ASHP, says pharmacists have a responsibility to take a prominent role in antimicrobial stewardship programs by
Joel Hennenfent, PharmD, system director, Pharmacy Services at Truman Medical Centers, a healthcare system in Kansas City, MO, says all its pharmacists are credentialed and privileged by the medical staff so that they can adjust dosage, frequency, and labs without conferring with a doctor. “A pharmacist is positioned as the practitioner who has a touch point in each aspect of the program,” he says.
The History of ASPs
Although ASPs have been around since the 1940s, it wasn’t until 2006 that the CDC outlined procedures for managing multidrug-resistant organisms in healthcare settings, followed two years later by guidelines for developing an ASP from the Infectious Diseases Society of America.
The CDC’s introduction of seven core elements in 2014, set the tone for more formal requirements. The elements include drug expertise realized by appointing a single pharmacist leader responsible for improving antibiotic use.
As many as 92.5% of hospitals have an ASP, according to ASHP.
Advancements in information technology and a proliferation of antibiotic-resistant organisms have put ASPs on the radar. These organisms account for more than 2 million Staphylococcus aureus and Clostridium difficile infections and 23,000 deaths in the United States, as reported in The Joint Commission Journal on Quality and Patient Safety in 2018.
Truman Medical Centers, the University of San Francisco (UCSF) Medical Center, and the University of Pittsburgh, among other hospitals nation-wide, have built their ASPs around a collaborative multidisciplinary team of pharmacists and clinicians, infectious diseases expertise, and information technology.
The ASP team at Truman works closely with Cerner, which combines EHRs and clinical decision support systems. These technology tools, along with an antibiogram, biomedical research, and metabolic and blood profiles, provide ASP pharmacists 24/7 with recommendations based on patient-specific information in real time. These suggestions help clinicians choose appropriate therapy, dosage, and frequency; avoid preventable errors; and share data on previous antibiotic treatments, diagnostic tests, and culture results.
By using Cerner, Truman also has developed flexible, automatic protocols for pharmacists, which minimizes calls to physicians, and has identified and prioritized the top 10 interventions for initial EHR integration.
“Our primary goal is to conserve antibiotics for those who need them and if possible, use fewer antibiotics or a narrower spectrum that is effective. Every exposure changes bacteria that can adapt and become drug resistant,” Hennenfent says.
Compared to a 2009 benchmark, Truman has consistently used 10% fewer antibiotics, increased streamlining to a narrow spectrum antibiotic by 457% with a corresponding reduction in broad-spectrum antibiotics and has maintained the program at 80% of the cost.
Alexandra Hilts-Horeczko, PharmD, clinical infectious diseases pharmacy specialist at UCSF, says its ASP has evolved into a more formal program primarily managed by the medical director, a pharmacy resident in infectious diseases, and her. The team works collaboratively with infection control, the microbiology department, and data management, which oversees tracking and utilization review. It follows the standard national requirements for such a program, including the core elements and incorporating a multidisciplinary team. Hilts-Horeczko points out that pharmacists are key to the success of an ASP because of their drug knowledge and understanding of the appropriateness of medications.
“Pharmacists have a finger on the pulse of antibiotics,” she says. “They not only have access to medications, but they also are in the best position to evaluate the use of antibiotics and whether a patient should change antibiotics, or continue or discontinue treatment.”
Since the enhancement of its ASP program in 2015, UCSF has realized a 10% decrease in the use of targeted anti-biotics for C. difficile/10,000 patient days.
The University of Pittsburgh Medical Center’s program started in 2002 and is one of the country’s longest running ASPs, says Brian Potoski, PharmD, is associate director of the Antibiotic Management Program there. “Our hospital is well positioned to treat infection because of a sufficient number of dedicated pharmacists and the use of technology.”
With the help of TheraDoc, which provides clinical decision support software, the Pittsburgh ASP is able to streamline broader drugs into narrower spectrum options, curtail antibiotic use, minimize resistance, eliminate redundant coverage, and make changes in therapy if necessary. It also relies on blood tests that can determine what organism is present and what its resistance profile is.
To track results, Potoski studies a variety of markers, including how long it takes to find the most effective antibiotic, mortality, lengths of stay, days in an ICU, and total cost.
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Hennenfent says the success of his ASP rides on the full complement of clinicians on the program’s team. This includes an infectious diseases pharmacist who is the day-to-day ASP manager, an information technology pharmacist, a clinical pharmacy manager, and an infectious disease physician.
Hilts-Horeczko agrees that a collaborative team is the key to success, along with the incorporation of ASP core elements and support from the hospital’s administration, which she says understands the ASP’s need for additional resources.
To be successful, ASP programs must be realistic about a hospital’s specific issues and understand where problems, such as using the wrong antibiotic, exist and how they can be solved, Potoski says. It’s also important to use rapid diagnostics to determine the kind of infection and its profile for resistance, he says.
Jumping Over Barriers
The three ASPs share many of the same challenges. At Truman, Hennenfent says he is concerned about potential drug and antibiotic mismatches, transitioning patients out of a hospital, converting from IV to oral administration of antibiotics, and streamlining antibiotics.
The biggest challenges of antibiotics, Hilts-Horeczko says, are overuse-pre-scribed but not needed, which causes resistance and overuse-and choosing a drug too broad to treat a specific infection. “Manufacturers just are not developing antibiotics fast enough so we are turning to older drugs or combinations of these drugs,” she says.
Another challenge is improving tri- age of patients with infections. At press time, Hilts-Horeczko is monitoring 153 patients with infections at the medical center’s 782-bed, Parnassus cam- pus. A new module recently added to UCSF’s current EPIC system is developing a scoring system to rate severity.
Potoski’s frustration lies with a loss of autonomy when pharmacists have to call a physician if a change in an antibiotic is needed.