Health systems urged to adopt antibiotic stewardship programs by March 2020.
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:
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.
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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.