Antibiotic Stewardship
Maria G. Tanzi, PharmD
Antibiotic stewardship programs (ASPs) must be implemented at all acute-care hospitals that participate in Medicare and Medicaid by March 30, 2020, according to a new CMS rule released late last year. This requirement will ensure that small and critical-access hospitals also adopt ASPs in an effort to promote appropriate antibiotic use.
“The majority of large hospitals, such as academic institutions, have robust ASPs run by expert infectious disease physicians and pharmacists; however, smaller, community-based centers may lack the infrastructure, resources, and training to implement such programs,” said Amy Hanson, PharmD, BCPS AQ-ID, who’s an antimicrobial stewardship and infectious disease pharmacist at the Chicago Department of Public Health. “Getting leadership buy-in and providing staff with the appropriate training will help the ASPs and ultimately improve patient care.”
New rule
The CMS rule requires hospitals to implement a robust ASP that follows nationally recognized guidelines for appropriate antibiotic use. The program must be hospitalwide for the surveillance, prevention, and control of hospital-acquired infections and for other infectious diseases. CMS encourages multisystem hospitals to have an integrated ASP with a single governing body that ensures compliance throughout the system.
CMS has guidance specific to critical-access hospital ASPs:
- Demonstrate coordination among all components of the critical access hospital responsible for antibiotic use and resistance, including but not limited to the infection prevention and control program, the quality assurance and performance improvement program, the medical staff, and nursing and pharmacy services.
- Document the evidence-based use of antibiotics in all departments and services of the critical-access hospital.
- Provide proof of improvements, including sustained improvements, in proper antibiotic use, such as reductions in Clostridium difficile infections and antibiotic resistance in all hospital departments and services.
Leadership buy-in and education are integral components
Hanson discussed the importance of getting leadership buy-in to ensure the appropriate allocation of resources necessary to support an ASP. Strategies may include designating an individual who reports to the C-suite to be accountable for the outcomes of the ASP and integrating stewardship activities into ongoing quality improvements and/or patient safety efforts.
Hanson also commented that many small hospitals do not have staff dedicated solely to the program. “I have called numerous smaller hospitals across the Chicago area and asked who is in charge of their ASP. Oftentimes, it’s the director of pharmacy who states he or she is accountable,” Hanson said.
“Given all of their administrative duties, it will be difficult for them to effectively lead a program.”
Therefore, ensuring that everyone involved is properly educated in antibiotic stewardship is essential. All staff who may be involved should receive appropriate training via online or live courses and dedicated time for daily activities in clinical antimicrobial stewardship. The Society of Infectious Disease Pharmacists offers a certificate program for hospital pharmacists to receive appropriate training to lead an ASP in a smaller hospital where, for example, pharmacists residency trained in infectious disease may not be available.
The majority of antibiotic use in hospitals has centered around three main conditions: community-acquired pneumonia, urinary tract infections, and skin and soft tissue infections. Education on interventions such as implementing appropriate diagnostic criteria and rules around empiric therapy, enforcing adherence to institution-specific treatment guidelines, and treating conditions for the shortest-effective duration can substantially improve antibiotic use.
Other strategies to seek additional expertise may include joining multi-hospital improvement collaborations through remote consultation (e.g., telemedicine) when needed, or investigating if your local or state health department has an antimicrobial stewardship expert available to evaluate and provide feedback to enhance your facility’s ASP.
Team-based approach is key
Team-based approaches to antibiotic stewardship can also be very effective in small hospitals. For example, pharmacists can review antibiotics for duplication of therapy and opportunities for I.V. to oral conversions, as well as monitor medication safety. This can be accompanied by nurses reviewing the culture results with the treating physician and pharmacist, monitoring the patient for response to antibiotic therapy, and alerting providers when a patient’s clinical status has changed and oral intake may be an option.
Hanson said that involvement in the formulary review process is another area hospital pharmacists can become involved in, especially given the recent approval of several broad-spectrum antibiotics. “Pharmacists can work with other interdisciplinary staff members to protect access to select antibiotics via an approval pager held by an infectious disease specialist, and keep the formulary lean by removing antibiotics from formulary as needed,” she noted.