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"Make Antibiotics Great Again:" A Reflection on Antibiotic Stewardship

MAR 30, 2017 | KRISTI ROSA
When it comes to the pros of these requirements, Dr. Cosgrove said, “I do think that there’s good synergy and alignment with the CDC Core Elements [and] societies, particularly SHEA and IDSA, and groups writing and enforcing the requirements (such TJC and Centers for Medicare and Medicaid Services, or CMS).” She added, “There are also many components of the requirements that are reasonable and actionable,” such as the requirement of having leadership support, having it fall under “Medication Management” rather than “Infection Control,” and the adequate emphasis on the importance of interventions, which “are the bread and butter of antibiotic stewardship.”

One of the biggest issues that Dr. Cosgrove noted with regards to the acute care requirements was that there is a notable lack of understanding when it comes to how the TJC will assess ASPs during survey. “There seems to be a focus on the patients that we do not usually touch in stewardship programs. In fact, it’s like, if you wanted to pick a group of patients in the hospital that the stewardship program is generally not involved with, it’s this list of patients that TJC says they are going to focus on during the survey.” said Dr. Cosgrove. These patients include “emergency department patients who are prescribed antimicrobials, ambulatory and clinic patients surveyed under the hospital program who are prescribed antimicrobials, [and] hospitalized patients who will be discharged on antimicrobials.”

Even though there were two elements of performance that focused on educating healthcare workers and patients, Dr. Cosgrove said that this education was “of uncertain value.” Since ASPs work on smaller budgets, and sometimes no funding at all, “they must optimize how time is spent.” She said, “I’m concerned that us running off and making education modules, and trying to deal with patients in the ambulatory clinic is really not where the focus of our program should be. We need to ensure that as we are compliant with TJC standard, that this is not superseding our ability to really do the interventions we need to do on the patients who are really affected by suboptimal antibiotic use.”

She also touched on the CMS requirements pertaining to long-term care, which is particularly important since there are 15,000 facilities and 1.5 million residents of these facilities who are reimbursed by CMS. The CMS infection control requirements for long-term care have been revised to require ASPs starting on November 28, 2017; this means that facilities are required to have an infection prevention and control program (IPCP) that includes ASP, which should include “antibiotic use protocols and systems for monitoring antibiotic use” as well as “recording incidents and corrective actions taken by the facility.” Furthermore, IPCPs should be led by an infection control and prevention officer, and a pharmacist “must review the resident’s medical record when performing the monthly drug regimen review when the patient is receiving an antibiotic.”

Dr. Cosgrove emphasized that she feels that the CMS requirements focus on the most important AS components: “providing guidance for use, and monitoring use.” The fact that they are based on the CDC Core Elements is also a plus. However, she did have some issues with the CMS requirements as well. For example, she felt that, according to the language used in the Federal Register, leadership responsibilities seem to be placed with an infection control and prevention officer. She commented, “I understand why this is, because they’re trying to put someone in charge…but we know from our experience in the inpatient setting that physician and pharmacist leadership is likely needed for sustained change in antibiotic use.”

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