Joey Sweeney, PharmD, BCPS
In the United States, 77% of all UTIs and 47% of all community-acquired pneumonias (CAP) are treated inappropriately in the hospital setting, according to an expert panel convened by the Pew Charitable Trust in 2018 to evaluate antibiotic use in hospitals. The panel’s findings, which were published in a March 18, 2021, report, revealed that fluoroquinolones were used inappropriately 47% of the time, and vancomycin was used inappropriately 27% of the time.
Because any amount of antibiotic can contribute to creating resistant bacteria, it is important to appropriately limit use wherever possible, the report stated. It makes sense to focus on hospital prescribing, as 60% of patients receive antibiotics during their stays.
Ambitious targets
The Pew Charitable Trust panel of experts set ambitious targets to rapidly reduce the volume of inappropriate prescribing of fluoroquinolones and vancomycin and improve prescribing of antibiotics for CAP and UTI in hospitals.
For CAP and UTI, the panel set a 90% reduction in inappropriate prescribing. The panel said that up to 10% of antibiotics that appear to be inappropriate are reasonable, given a patient’s comorbidities.
For vancomycin and fluoroquinolones, the panel recommended a 95% reduction in inappropriate prescribing. The panel said that 5% of these antibiotic orders are allowable for rare exceptions.
“The implications of these data are clear,” said Tom Dilworth, PharmD, infectious diseases clinical coordinator for Advocate Aurora Healthcare. “As a profession, we need to prioritize antibiotic stewardship in our collective practice across the continuum of care, rather than implementing novel, hypothesis-generating antibiotic therapeutic drug monitoring strategies such as vancomycin [area under the curve].”
To achieve these aggressive targets, hospitals should invest in local antibiotic stewardship programs which aim to decrease harm from antibiotic prescribing, reduce or eliminate unnecessary antibiotic use, and avoid contributing to antibiotic resistance, the panel advised. In stating that small hospitals will need technical and financial support to create these programs, the panel recognized the importance of antibiotic stewardship programs in all hospitals.
Building a roadmap
The panel used data from CDC’s Emerging Infections Program (EIP) through its Healthcare-Associated Infections Community Interface activity. The EIP, comprising 10 state health departments along with their partners, collects data on health care–associated infections and antibiotic-resistant pathogens. Data collection began in 2011 but did not assess the appropriateness of antibiotic use.
In 2013, after CDC conducted a survey to evaluate appropriateness they found that fluoroquinolones and vancomycin had high rates of inappropriate use. In 2014 and 2015, CDC evaluated CAP and UTI treatments, as well as vancomycin and fluoroquinolone use.
CDC’s methodology was used to survey 192 hospitals across the United States as part of the Antimicrobial Quality Assessment Approach (AQUA) survey. The results of this survey were then used to set national targets for antibiotic use reduction.
Stewardship programs
The expert panel makes a compelling case to reduce inappropriate antibiotic use, but how hospitals can accomplish these objectives is unclear. The panel conceded that there is no “one-size-fits-all” approach to stewardship but said that hospitals should institute policies and activities to ensure they begin to track toward these goals.
Hospitals can report antibiotic use and compare their results with those of other hospitals through CDC’s National Healthcare Safety Network Antimicrobial Use and Resistance Option (NHSN AUR).
“All hospitals should strive to submit antibiotic use data to CDC’s NHSN AUR module. However, the complexities of AUR data submission make this challenging for some hospitals and health systems. Health care systems, electronic health record vendors, and CDC need to work together to reduce AUR submission barriers so that more hospitals can submit antibiotic use data to NHSN AUR,” said Dilworth.
Hospitals and health systems have a lot of work to do to reduce inappropriate ordering of antimicrobials. They can use resources such as the NHSN AUR and focus their antibiotic stewardship program efforts on making real progress. “We need to do the most value-added and patient-focused work we can in our profession—and for antibiotics, that means engaging with providers and stopping unnecessary and inappropriate antibiotic therapy whenever possible,” said Dilworth.