Antimicrobial Stewardship in Action

A real-life look at the CDC's core elements of antimicrobial stewardship in practice at two leading institutions.

The White House, The Joint Commission, and an increasing number of other stakeholders are doubling down on antimicrobial stewardship, saying that the time is now to stem the tide of antibiotic-resistance. Late last month, The Joint Commission released its proposed standard focusing on Antimicrobial Stewardship, which is now open for field review. The proposed standards call for an "antimicrobial stewardship program based on evidence-based national guidelines" in ambulatory healthcare organizations, critical access hospitals, hospitals, nursing care centers, and office-based surgery practices.

"The intent and outcome would be a standard," says Lisa Waldowski, MS, APRN, CIC, infection control specialist for The Joint Commission enterprise.

She says such a standard is a long way off, and is still very much in development: The proposed standards are out for field review through December 30 and will be going through a vetting, development, and approval process all next year. Plus, the Joint Commission would give a long lead time for organizations to have a chance to implement such a standard.

"It will be coming, but I don't think we're going to see this in the next year," she says. Still, "this is not going to come as a surprise ... we're moving toward that future state."

"This is not a new issue. Now it's just being supported at a higher level," Waldowski adds. "We have created this conundrum that we're under now. We really have to say we can't bide anymore time. We really don't have the luxury or the time to spare."

Doing it for patients

It's not just the Joint Commission that could potentially push hospitals and other organizations toward implementing stewardship programs. There's also a push for having antimicrobial stewardship teams in each hospital as a condition for participation in Medicare/Medicaid by end of 2017, notes Mohamad Fakih, MD, national infectious diseases physician leader at Ascension Health in Detroit.

But in the meantime, he says, "I think it's the right thing to do for those we serve …. We're doing this to improve our patients' outcomes."

Antimicrobial stewardship is likewise a priority at Northwestern Memorial Hospital in Chicago, which has had a formalized program since 2002.

"There's been an incredible increased intensity and awareness in our government and regulatory bodies," Sarah Sutton, MD, medical director of the Antimicrobial Stewardship Program at Northwestern Memorial Hospital and assistant professor in the Division of Infectious Disease at Northwestern University Feinberg School of Medicine. "I like to say that gone are the days of cowboy antibiotic use when every prescriber just followed his own rules and his own habits."

CDC recommendations in practice

Despite robust efforts at some organizations, though, there are certainly others that are behind the eight ball in implementing antimicrobial stewardship programs. Waldowski says the CDC's core elements of hospital antibiotic stewardship programs provide excellent guidance for any program.

The CDC's core elements are:

• Leadership Commitment: Dedicating necessary human, financial, and information technology resources 
• Accountability: Appointing a single leader responsible for program outcomes. Experience with successful programs shows that a physician leader is effective
• Drug Expertise: Appointing a single pharmacist leader responsible for working to improve antibiotic use
• Action: Implementing at least one recommended action, such as systemic evaluation of ongoing treatment need after a set period of initial treatment (e.g., an "antibiotic time out" after 48 hours)
• Tracking: Monitoring antibiotic prescribing and resistance patterns
• Reporting: Regular reporting information on antibiotic use and resistance to doctors, nurses, and relevant staff
• Education: Educating clinicians about resistance and optimal prescribing

The Ascension Health and Northwestern programs embody these elements. Here's how:

Leadership commitment: According to Fakih, Ascension's leaders have made a commitment to support improved antimicrobial use in all of its facilities, and have "created a Center of Excellence for Antimicrobial Stewardship and Infection Prevention for the whole system to optimize antimicrobial use across the care continuum.

"A critical factor to success in most organizations is the commitment from leadership. Until recently, antimicrobial stewardship has not been on the radar screen for most of the U.S. hospitals," he says. "Leadership also helps engage the different stakeholders and have their goals aligned with best practices."

For instance, the chief medical officer plays a big role; if members of the pharmacy team are working on it, but physicians are not onboard, the program won't work. It needs to be clear that administration is fully supportive, including physician leadership. When hospitals within Ascension's system aren't doing as well with stewardship, they get a call and perhaps also a site visit with their CEO, CMO, physician leaders, laboratory leaders, directors of pharmacy, and all others that will affect the care, so they can hear recommendations directly.

The CEO must also be onboard in action, as well as word.

"The big message that I would give the leadership is that resources need to be provided to the antimicrobial stewardship team," Sutton says. That includes IT resources and having dedicated employees to do the work. "These programs are labor intensive and do need resources."

Accountability and drug expertise: The CDC calls for appointing a single leader who's responsible for program outcomes, preferably a physician, as well as a single pharmacist leader who's responsible for working to improve antibiotic use. The program should create a climate where they work together daily and medications are reviewed daily, Fakih says.
A physician can lead the way in the program, educate colleagues, and work with pharmacy, but the pharmacist leader has to have power, too, especially in challenging a physician's prescribing choices.

"It's not going to be just saying we're committed, we have to do some action. You need to empower the pharmacists," Fakih says.

Implementing at least one recommended action: Sutton says it's important to choose to work on issues that will have early success; programs shouldn't take on the biggest challenges first. Small successes will lead to larger efforts.

Also, Northwestern has chosen a specific issue as their "rallying cry:" reducing Clostridium difficile–associated diarrhea (CDAD).

"For each individual, recent antibiotic use is the strongest risk factor linked to the development of Clostridium difficile diarrhea. In addition, for in-patients within a ward or facility, there is building evidence that the community antibiotic load is also linked with risk of developing CDAD," Sutton said later via email. Northwestern Memorial Hospital's antimicrobial stewardship program "is partnering with the hospital, clinicians, pharmacists, IT, and patients to reduce the in-patient antibiotic load as a means of reducing CDAD."

Tracking and reporting: Sutton says order sets are critical. For instance, Northwestern's CPOE gives prescribers information such as what antibiotics the patient is on now, the dose, the interval, start date, and original indication, as well as past antibiotic use, "so the clinician sees a bigger picture." Order sets also give prescribers a limited number of options, rather than the whole spectrum of antibiotics, so that they're less likely to choose one that's inappropriate. 

Waldowski says linking antibiotic usage to defined metrics is also key. For instance: Are costs going down thanks to wiser prescribing? Are there fewer cases of Clostridium difficile? And, as mentioned before, the physician-pharmacist team should be reviewing antibiotic use daily for appropriateness.

Education: Although each of the above is certainly critical to success, educating clinicians and getting them to make change might represent the biggest hurdle.

"Even if you have all the technical stuff mastered … culture can limit your success," Fakih says.

Waldowski agrees, saying, "The easier part is to create the recommendations, create the policies and procedures, write the standards."

But as Sutton says, "Hospitals need to be aware that changing a culture is a really challenging thing to do, and that's what's really indicated to reducing antibiotic overuse."

Sutton says that no matter how much momentum there is behind decreased and smarter antibiotic use, there will always be holdouts who resist change and "feel very strongly with their use of antibiotics," even if it "doesn't fall into line with approaches to modern antibiotic use." Plus, prescribers often learn from their mentors and do what they've been taught, thus perpetuating inappropriate antibiotic use.

For all of these reasons, educating clinicians is critically important. Sutton says clinician education should include providing data in a way that's easily digested, showing them scientific literature, and sharing data about concrete improvements, such as differences in Clostridium difficile rates when the institution is using fewer antibiotics. It's also important to reassure clinicians that they're not putting their patients at risk when they change their antibiotic prescribing.

"Clinicians are really trying to do the best for the patients," she says. "But they need that reassurance that they're going to be OK."