H o s p i t a l A n t i m i c ro b i a l S t e w a rd s h i p i n t h e N o n u n i v e r s i t y Setting Kavita K. Trivedi,
MD
a,
*, Kristi Kuper,
PharmD, BCPS
b
KEYWORDS Antimicrobial stewardship Community hospitals Small hospitals Rural hospitals Long-term acute care hospitals KEY POINTS Inappropriate antimicrobial use and antimicrobial resistance are problems that persist across the healthcare continuum. Several hospitals with limited infectious diseases resources have found ways to use available personnel to perform antimicrobial stewardship activities, with documented improvements in antimicrobial use and reductions in resistance and cost. Specific antimicrobial stewardship strategies are more feasible and effective in settings with limited infectious diseases resources.
INTRODUCTION
Regardless of the type of healthcare facility (large or small, urban or rural, academic or community) there is a 50% chance of a hospitalized patient receiving an antibiotic.1 Studies have estimated that antimicrobial therapy is inappropriate and suboptimal 30% to 50% of the time for patients in acute healthcare settings.2,3 Furthermore, inappropriate use of antimicrobial agents creates favorable conditions for resistant microorganisms to emerge, spread, and persist. To prevent the spread of antimicrobial resistance, US Centers for Disease Control and Prevention recommends every hospital optimize antimicrobial prescribing, also known as antimicrobial stewardship.4,5 Antimicrobial stewardship is a responsibility of all healthcare institutions, regardless of size,6 to provide careful guidance and oversight of antimicrobials,3 which can be provided through an antimicrobial stewardship program (ASP). An ASP promotes and measures the appropriate use of antimicrobial agents with the goals of minimizing adverse events, achieving optimal patient outcomes, limiting selective pressures that
Disclosure: Neither author has any relevant financial disclosures. a Trivedi Consults, LLC, 1020 Curtis Street, Albany, CA 94706, USA; b VHA Performance Services, 521 East Morehead Street, Suite 300, Charlotte, NC 28202, USA * Corresponding author. E-mail address: [email protected] Infect Dis Clin N Am 28 (2014) 281–289 http://dx.doi.org/10.1016/j.idc.2014.01.007 0891-5520/14/$ – see front matter Ó 2014 Elsevier Inc. All rights reserved.
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lead to the emergence of resistant organisms and Clostridium difficile, as well as reducing overall healthcare costs. An ideal ASP is a comprehensive system of multidisciplinary healthcare providers, dedicated policies and procedures, and methods for data collection and outcomes reporting that promote optimal use of antimicrobial agents across the continuum of care. However, in many settings with limited infectious diseases expertise, information technology, and financial resources, these elements are not available because of lack of funding and/or personnel,7 although programs have been developed and have prospered despite these barriers. The ASP policy statement developed by the Society of Healthcare Epidemiology of America (SHEA), Infectious Diseases Society of America (IDSA), and Pediatric Infectious Diseases Society specifically recommends that the Centers for Medicare and Medicaid Services require all healthcare institutions (both inpatient and outpatient settings) to develop ASPs.6 These ASPs are to be developed in accordance with the 2007 IDSA/SHEA guidelines and include a multidisciplinary team, antimicrobial formulary, institutional-specific guidelines for common infectious syndromes, interventions to improve antimicrobial use, facility-specific antibiograms, and processes to measure and monitor antimicrobial use.3,6 Although developing a successful ASP is a challenge in any healthcare setting, there are unique challenges to hospitals with limited resources (eg, small, rural), where limited staffing and infrastructure may hamper the ability to implement ideal antimicrobial stewardship strategies. However, successful ASPs have been implemented in a variety of nonuniversity settings, and the experience with these efforts is instructive. Most of the published data on antimicrobial stewardship in hospital settings comes from experiences in academic centers,8–10 leading to a misconception that successful ASPs are only possible in settings with plentiful resources, including physicians and pharmacists with specialized training in infectious diseases (ID), personnel-in-training (eg, medical and pharmacy residents and fellows), informatics systems and technical support, and administrative support and funds. It is often assumed that healthcare settings with more limited resources (eg, community hospitals, small [fewer than 100 licensed beds] and/or rural hospitals), and long-term acute care hospitals (LTACHs) are incapable of supporting ASPs. However, it is useful to think of ASPs as a menu of interventions that are customizable and may be applied to any healthcare setting.11 A survey conducted in 568 US hospitals (most of which were community hospitals) indicates a diversity of resources available to implement ASPs.11 Many of the components of an ASP may already be in place but not formalized. In a national survey of 406 hospitals antimicrobial stewards strategies such as guidelines/clinical pathways (66%) and parenteral-to-oral conversion protocols (64%) were reported in hospitals that did not consider themselves to have a formal ASP.12 In a 2010 survey of pharmacy directors at 563 hospitals, 91% of respondents reported having a pharmacokinetic dosing program, and 84% had a mechanism in place to evaluate antibiotic use.13 Staff pharmacists often perform these functions as part of their daily clinical activities, but other components of an ASP as recommended by the IDSA/SHEA guidelines may not be in place.3 A 2011 national survey found that only 23% of community hospital ASPs were compliant with the IDSA/SHEA guidelines, compared with 55% of academic medical centers.14 The most frequent barrier cited was lack of funding and/or personnel. A mandate for processes encouraging the judicious use of antibiotics has existed for general acute care hospitals in California since 2008. In an assessment of 162 community hospitals in California conducted between 2010 to 2011, 49% reported an active ASP and 32% reported planning an ASP.15 By beginning with efficient planning that focuses on problems or issues that can be addressed with available resources, effective ASPs are possible in the community hospital inpatient setting.
Nonuniversity Hospital Antimicrobial Stewardship
Community Hospitals
Community hospitals have been successful at implementing ASPs when they use targeted antimicrobial stewardship strategies and available personnel, and do not focus on the lack of ID expertise, if that is absent. One of the earliest published reports of an ASP in a community hospital documented the experience of a 120-bed hospital in Louisiana in 2003.16 The ASP team consisted of an ID specialist, staff pharmacist, infection preventionists, and microbiologists. The team performed chart reviews 3 times per week. Total physician time invested in the ASP was between 8 and 12 hours per week. Patients receiving multiple, prolonged, or high-cost therapy were targeted. Notes or telephone calls were made to physicians if an intervention was recommended. The most frequent interventions were antimicrobial streamlining, conversions from parenteral to oral medications, and dose optimization. Over a 12-month intervention period, 488 recommendations were made, with an acceptance rate of 69%. Antibiotic costs declined from $18.21 per patient-day to $14.77 per patient-day (a reduction of 19%), which equated to total savings of $177,000. Although clinical outcomes were not formally evaluated, no adverse events were reported attributable to the ASP. ASPs in community hospitals commonly begin on a smaller scale by evaluating antimicrobial usage patterns and resistance trends, and then devising interventions targeted at a single antimicrobial agent or class that is thought to be misused. For example, the use of fluoroquinolones as empiric therapy for Pseudomonas aeruginosa infections was the focus of a pharmacy-led ASP in a 565-bed, acute care, community teaching hospital in southern California.17 This target is especially relevant because fluoroquinolones are the leading class of antimicrobial agents prescribed to adults in the US and fluoroquinolone resistance is a significant problem.18 Components of this hospital’s ASP included: Drug audits with post-prescription review and feedback Automatic intravenous (IV)-to-oral conversion programs A b-lactam–based institutional guideline for the treatment of Pseudomonas aeruginosa infections Educational programs targeting appropriate fluoroquinolone use These interventions resulted in a 30% decrease in fluoroquinolone use since the inception of its ASP.17 Community teaching hospitals in Michigan and Toronto also used a drug-centric approach for their ASP initiatives. The Michigan program was composed of ID physicians and ID pharmacists who prospectively audited new antimicrobial starts and the weekly use of 8 target antimicrobials.19 They showed significant reductions in Clostridium difficile rates, antimicrobial use, and pharmacy costs.19 The program at the Canadian hospital was also composed of an ID physician and ID pharmacist and targeted a 12-bed intensive care unit, showing a reduction in antimicrobial costs and use of antipseudomonal agents with a prospective audit and feedback program in just 9 months.20 A perceived challenge for community hospital ASPs is the absence of both an ID physician and an ID pharmacist as per the IDSA/SHEA guidelines. In a national survey of smaller hospitals (80% with 25–300 beds), only 59% had an ID physician specialist on staff or available.11 In another evaluation of 406 US hospitals, mostly nonteaching facilities, only 35% reported having an ID pharmacist.12 Despite this resource limitation, there are reports of ASPs that have been implemented in community hospitals without dedicated ID resources. For example, a 236-bed acute care community
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hospital in Maryland established an ASP using existing clinical pharmacy resources with only remote access to an ID pharmacist for 16 hours per month.21 An ID physician was consulted for administrative issues and shared chairperson responsibilities for the antimicrobial stewardship subcommittee, but no ID physician hours were dedicated to support daily ASP activities. The key components of the ASP included formulary restriction and prospective audit and feedback. Restricted antimicrobials were limited to prescription by an ID physician or intensivist (within the first 72 hours of admission) only. Patients receiving broad-spectrum antimicrobials were prospectively reviewed by a clinical pharmacist for appropriate use and streamlining potential. Automatic renal dose adjustment and IV-to-oral conversion was performed by staff pharmacists as part of the ASP. Data on select antimicrobials were gathered daily and aggregated quarterly for presentation to the antimicrobial stewardship subcommittee to identify trends. This information was also used in physician credentialing and communicated routinely to the Chief Medical Officer to improve physician compliance. Over a 2-year period, antimicrobial use, as measured by defined daily doses (DDD) decreased from 821.33 to 778.77 DDD/1000 patient-days (P
MD
a,
*, Kristi Kuper,
PharmD, BCPS
b
KEYWORDS Antimicrobial stewardship Community hospitals Small hospitals Rural hospitals Long-term acute care hospitals KEY POINTS Inappropriate antimicrobial use and antimicrobial resistance are problems that persist across the healthcare continuum. Several hospitals with limited infectious diseases resources have found ways to use available personnel to perform antimicrobial stewardship activities, with documented improvements in antimicrobial use and reductions in resistance and cost. Specific antimicrobial stewardship strategies are more feasible and effective in settings with limited infectious diseases resources.
INTRODUCTION
Regardless of the type of healthcare facility (large or small, urban or rural, academic or community) there is a 50% chance of a hospitalized patient receiving an antibiotic.1 Studies have estimated that antimicrobial therapy is inappropriate and suboptimal 30% to 50% of the time for patients in acute healthcare settings.2,3 Furthermore, inappropriate use of antimicrobial agents creates favorable conditions for resistant microorganisms to emerge, spread, and persist. To prevent the spread of antimicrobial resistance, US Centers for Disease Control and Prevention recommends every hospital optimize antimicrobial prescribing, also known as antimicrobial stewardship.4,5 Antimicrobial stewardship is a responsibility of all healthcare institutions, regardless of size,6 to provide careful guidance and oversight of antimicrobials,3 which can be provided through an antimicrobial stewardship program (ASP). An ASP promotes and measures the appropriate use of antimicrobial agents with the goals of minimizing adverse events, achieving optimal patient outcomes, limiting selective pressures that
Disclosure: Neither author has any relevant financial disclosures. a Trivedi Consults, LLC, 1020 Curtis Street, Albany, CA 94706, USA; b VHA Performance Services, 521 East Morehead Street, Suite 300, Charlotte, NC 28202, USA * Corresponding author. E-mail address: [email protected] Infect Dis Clin N Am 28 (2014) 281–289 http://dx.doi.org/10.1016/j.idc.2014.01.007 0891-5520/14/$ – see front matter Ó 2014 Elsevier Inc. All rights reserved.
id.theclinics.com
282
Trivedi & Kuper
lead to the emergence of resistant organisms and Clostridium difficile, as well as reducing overall healthcare costs. An ideal ASP is a comprehensive system of multidisciplinary healthcare providers, dedicated policies and procedures, and methods for data collection and outcomes reporting that promote optimal use of antimicrobial agents across the continuum of care. However, in many settings with limited infectious diseases expertise, information technology, and financial resources, these elements are not available because of lack of funding and/or personnel,7 although programs have been developed and have prospered despite these barriers. The ASP policy statement developed by the Society of Healthcare Epidemiology of America (SHEA), Infectious Diseases Society of America (IDSA), and Pediatric Infectious Diseases Society specifically recommends that the Centers for Medicare and Medicaid Services require all healthcare institutions (both inpatient and outpatient settings) to develop ASPs.6 These ASPs are to be developed in accordance with the 2007 IDSA/SHEA guidelines and include a multidisciplinary team, antimicrobial formulary, institutional-specific guidelines for common infectious syndromes, interventions to improve antimicrobial use, facility-specific antibiograms, and processes to measure and monitor antimicrobial use.3,6 Although developing a successful ASP is a challenge in any healthcare setting, there are unique challenges to hospitals with limited resources (eg, small, rural), where limited staffing and infrastructure may hamper the ability to implement ideal antimicrobial stewardship strategies. However, successful ASPs have been implemented in a variety of nonuniversity settings, and the experience with these efforts is instructive. Most of the published data on antimicrobial stewardship in hospital settings comes from experiences in academic centers,8–10 leading to a misconception that successful ASPs are only possible in settings with plentiful resources, including physicians and pharmacists with specialized training in infectious diseases (ID), personnel-in-training (eg, medical and pharmacy residents and fellows), informatics systems and technical support, and administrative support and funds. It is often assumed that healthcare settings with more limited resources (eg, community hospitals, small [fewer than 100 licensed beds] and/or rural hospitals), and long-term acute care hospitals (LTACHs) are incapable of supporting ASPs. However, it is useful to think of ASPs as a menu of interventions that are customizable and may be applied to any healthcare setting.11 A survey conducted in 568 US hospitals (most of which were community hospitals) indicates a diversity of resources available to implement ASPs.11 Many of the components of an ASP may already be in place but not formalized. In a national survey of 406 hospitals antimicrobial stewards strategies such as guidelines/clinical pathways (66%) and parenteral-to-oral conversion protocols (64%) were reported in hospitals that did not consider themselves to have a formal ASP.12 In a 2010 survey of pharmacy directors at 563 hospitals, 91% of respondents reported having a pharmacokinetic dosing program, and 84% had a mechanism in place to evaluate antibiotic use.13 Staff pharmacists often perform these functions as part of their daily clinical activities, but other components of an ASP as recommended by the IDSA/SHEA guidelines may not be in place.3 A 2011 national survey found that only 23% of community hospital ASPs were compliant with the IDSA/SHEA guidelines, compared with 55% of academic medical centers.14 The most frequent barrier cited was lack of funding and/or personnel. A mandate for processes encouraging the judicious use of antibiotics has existed for general acute care hospitals in California since 2008. In an assessment of 162 community hospitals in California conducted between 2010 to 2011, 49% reported an active ASP and 32% reported planning an ASP.15 By beginning with efficient planning that focuses on problems or issues that can be addressed with available resources, effective ASPs are possible in the community hospital inpatient setting.
Nonuniversity Hospital Antimicrobial Stewardship
Community Hospitals
Community hospitals have been successful at implementing ASPs when they use targeted antimicrobial stewardship strategies and available personnel, and do not focus on the lack of ID expertise, if that is absent. One of the earliest published reports of an ASP in a community hospital documented the experience of a 120-bed hospital in Louisiana in 2003.16 The ASP team consisted of an ID specialist, staff pharmacist, infection preventionists, and microbiologists. The team performed chart reviews 3 times per week. Total physician time invested in the ASP was between 8 and 12 hours per week. Patients receiving multiple, prolonged, or high-cost therapy were targeted. Notes or telephone calls were made to physicians if an intervention was recommended. The most frequent interventions were antimicrobial streamlining, conversions from parenteral to oral medications, and dose optimization. Over a 12-month intervention period, 488 recommendations were made, with an acceptance rate of 69%. Antibiotic costs declined from $18.21 per patient-day to $14.77 per patient-day (a reduction of 19%), which equated to total savings of $177,000. Although clinical outcomes were not formally evaluated, no adverse events were reported attributable to the ASP. ASPs in community hospitals commonly begin on a smaller scale by evaluating antimicrobial usage patterns and resistance trends, and then devising interventions targeted at a single antimicrobial agent or class that is thought to be misused. For example, the use of fluoroquinolones as empiric therapy for Pseudomonas aeruginosa infections was the focus of a pharmacy-led ASP in a 565-bed, acute care, community teaching hospital in southern California.17 This target is especially relevant because fluoroquinolones are the leading class of antimicrobial agents prescribed to adults in the US and fluoroquinolone resistance is a significant problem.18 Components of this hospital’s ASP included: Drug audits with post-prescription review and feedback Automatic intravenous (IV)-to-oral conversion programs A b-lactam–based institutional guideline for the treatment of Pseudomonas aeruginosa infections Educational programs targeting appropriate fluoroquinolone use These interventions resulted in a 30% decrease in fluoroquinolone use since the inception of its ASP.17 Community teaching hospitals in Michigan and Toronto also used a drug-centric approach for their ASP initiatives. The Michigan program was composed of ID physicians and ID pharmacists who prospectively audited new antimicrobial starts and the weekly use of 8 target antimicrobials.19 They showed significant reductions in Clostridium difficile rates, antimicrobial use, and pharmacy costs.19 The program at the Canadian hospital was also composed of an ID physician and ID pharmacist and targeted a 12-bed intensive care unit, showing a reduction in antimicrobial costs and use of antipseudomonal agents with a prospective audit and feedback program in just 9 months.20 A perceived challenge for community hospital ASPs is the absence of both an ID physician and an ID pharmacist as per the IDSA/SHEA guidelines. In a national survey of smaller hospitals (80% with 25–300 beds), only 59% had an ID physician specialist on staff or available.11 In another evaluation of 406 US hospitals, mostly nonteaching facilities, only 35% reported having an ID pharmacist.12 Despite this resource limitation, there are reports of ASPs that have been implemented in community hospitals without dedicated ID resources. For example, a 236-bed acute care community
283
284
Trivedi & Kuper
hospital in Maryland established an ASP using existing clinical pharmacy resources with only remote access to an ID pharmacist for 16 hours per month.21 An ID physician was consulted for administrative issues and shared chairperson responsibilities for the antimicrobial stewardship subcommittee, but no ID physician hours were dedicated to support daily ASP activities. The key components of the ASP included formulary restriction and prospective audit and feedback. Restricted antimicrobials were limited to prescription by an ID physician or intensivist (within the first 72 hours of admission) only. Patients receiving broad-spectrum antimicrobials were prospectively reviewed by a clinical pharmacist for appropriate use and streamlining potential. Automatic renal dose adjustment and IV-to-oral conversion was performed by staff pharmacists as part of the ASP. Data on select antimicrobials were gathered daily and aggregated quarterly for presentation to the antimicrobial stewardship subcommittee to identify trends. This information was also used in physician credentialing and communicated routinely to the Chief Medical Officer to improve physician compliance. Over a 2-year period, antimicrobial use, as measured by defined daily doses (DDD) decreased from 821.33 to 778.77 DDD/1000 patient-days (P
