Providers in other states can learn from this multiorganization collaborative that aims to improve antimicrobial utilization and prevent the emergence of antimicrobial resistance across South Carolina.
Antimicrobial resistance is an urgent public health threat. State and local health departments can play a critical role in promoting appropriate antimicrobial use and implement prevention strategies to help slow the development of antimicrobial resistance. The Antimicrobial Stewardship Collaborative of South Carolina (ASC-SC) was established in 2016 through a grant from the US Centers for Disease Control and Prevention. The South Carolina Department of Health and Environmental Control was the lead organization on the grant application, partnering with the University of South Carolina School of Medicine and College of Pharmacy. The goals of the collaborative are to coordinate and improve antimicrobial steward­ship across South Carolina and to improve surveillance to drive public health action. ASC-SC currently partners with 44 acute care hospitals and 12 long-term care facil­ities (LTCFs) to improve antimicrobial stewardship efforts in South Carolina.
ASC-SC offers free on-site, telephonic, and electronic antimi­crobial stewardship facility consults to health care facilities around the state. These focus on helping to initiate or improve existing stewardship programs. The new requirements from the Centers for Medicare & Medicaid Services (CMS) have prompted interest from LTCFs in improving their steward­ship programs. During the consults, LTCFs are provided with numerous resources and a visit summary outlining their progress in achieving each of the Core Elements of Antibiotic Stewardship for Nursing Homes. These core elements represent both CMS and Joint Commission require­ments for antimicrobial stewardship programs. ASC-SC also offers custom guidance to help improve achievement of each core element. At other facilities (eg, acute care hospi­tals), ASC-SC consults particularly focus on high-cost and/ or high-risk antibiotics, managing certain infectious disease states, or general resource restrictions.
REGIONAL AND STATEWIDE ANTIBIOGRAMS
ASC-SC also leads the state’s effort to generate a statewide anti­biogram. All members of the collaborative receive an annual copy of regional and statewide antibiograms. These data are compiled from antibiograms submitted to ASC-SC by facilities around the state. The statewide antibiogram provides facil­ities with an opportunity to compare their pathogens and antimicrobial resistance patterns to others in the region. This is particularly beneficial when it comes to predicting resis­tance patterns in organisms that are more likely to be hospi­tal-acquired, such as Pseudomonas aeruginosa or Acinetobacter baumannii, and organisms that may spread from facility to facility as patients are transferred. The statewide antibiogram is also useful to facilities and outpatient providers who do not have facility-specific antibiograms as it provides a general view of the resistance seen in a region, particularly when it comes to community-acquired organisms such as Escherichia coli. Regional and statewide antibiograms promote conversa­tion on potential statewide research and clinical intervention initiatives as well.
ASC-SC recognizes that many institutions do not have the resources to put together their own infectious syndrome— specific guidelines and initiatives. To better aid prescribers in the community, ASC-SC has developed several syndrome-spe­cific guidelines to improve prescribing practices. One example comes from ASC-SC’s collaboration with the Midlands Ambulatory Antimicrobial Initiative to develop guidelines for the management of acute sinusitis in adults. In addition, anti­microbial stewardship initiatives targeting emergency depart­ments (EDs) and LTCFs on the management of urinary tract infections (UTIs) and asymptomatic bacteriuria have been developed and implemented. Multicenter projects to improve antibiotic prescribing behaviors in UTIs are ongoing at EDs and LTCFs throughout South Carolina.
ASC-SC hosts regional and statewide antimicrobial stew­ardship meetings each year. The goals of these meetings are to provide current antimicrobial stewardship educa­tion to those attending, provide a forum for collaboration between participants from different facilities, and update alliance members on current initiatives and opportunities. At these meetings, members are asked to share successful antimicrobial stewardship initiatives at their local facilities to showcase the best antimicrobial practices in the state. Keynote presentations and breakout sessions provide valu­able opportunities for education and networking.
ASC-SC also recently started hosting live webinars, with a question-and-answer session on infectious diseases and antimicrobial stewardship topics. They are conducted on the fourth Tuesday of every other month. Although these webi­nars are intended to educate and provide collaboration for those in South Carolina, everyone is invited to participate and learn from them. Example topics include “Exploring prophylactic therapies for Clostridium difficile infection” and “Improving outcomes for patients with penicillin allergies.”
In addition to these scheduled educational meetings and webinars, ASC-SC provides education on an as-needed basis to those who request it. Examples include education for resi­dents and families at nursing homes, presentations targeting certain key challenges to nursing home administrators, and education for consultant pharmacists on how they can play an active role in antimicrobial stewardship.
TRACKING ANTIMICROBIAL UTILIZATION IN HOSPITALS AND AMBULATORY SETTINGS
A major goal of ASC-SC has been to increase the number of facilities in South Carolina submitting antimicrobial use and resistance data to the National Health Safety Network (NHSN) Antimicrobial Use and Resistance Module. The Antimicrobial Use (AU) Option facilitates risk-adjusted intra- and inter-fa­cility benchmarking of antimicrobial usage. The Antimicrobial Resistance (AR) Option facilitates evaluation of resistance data using a standardized approach to help providers with deci­sion-making and to provide facility-specific measures that allow for regional and national benchmarking. To achieve this goal, ASC-SC has provided education on the benefits of the module at regional and statewide meetings and connected institutions around the state that recently started submitting their anti­biotic use to NHSN. In 2016, when ASC-SC was formed, no hospital in South Carolina was submitting data to the AU or AR Options. As of November 9, 2018, there are 19 facilities submitting to the AU Option and 12 to the AR Option.
ASC-SC has also been analyzing aggre­gated ambulatory oral antibiotic prescription rates and associated medical claims rate data from Medicaid and the State Employee Health Plan dating back to 2014. These data can be broken down by antibiotic class, prescriber type, geographical setting (urban vs rural), etc. Results have revealed important trends in antimicrobial use and resistance patterns, which have sparked new initiatives and inter­ventions. In addition, ASC-SC is collecting data on C difficile infection (CDI) cases in South Carolina. Recently at IDWeek 2018, Mariam Younas, MD, ASC-SC hospital epidemiologist, presented the oral abstract, “Clostridium difficile Infection and Antibiotic Prescription Rates in the Community: Explaining the Gender Gap.”1 The data demonstrated that the incidence rate of community-associated CDI and the antibiotic prescription rate were higher in women than in men among groups aged 18 to 39 years and 40 to 64 years. However, after adjustment for antibiotic prescriptions, there was no significant difference in community-associated CDI rates in either age group. Using this outpatient oral anti­biotic prescription and fill data, we plan to identify provider groups that may benefit from further antimicrobial steward­ship education and initiatives to help decrease our ambula­tory antibiotic prescribing rates, targeting certain high-risk oral antibiotics, such as the fluoroquinolones, third-generation cephalosporins, and clindamycin.
ASC-SC is an example of a successful collaboration by a state health department, academic institutions, community hospitals, and LTCFs, with a shared goal of improving anti­microbial utilization and preventing the emergence of antimi­crobial resistance across a state. This is being tackled in a variety of ways, including providing education and resources via facility consults, local antibiograms, educational meetings and webinars, syndrome-specific guidelines and initiatives, and data on local antibiotic use and CDI rates.
Dr. Rac is the lead antimicrobial stewardship pharmacist of the Antimicrobial Stewardship Collaborative of South Carolina and a clinical instructor at the University of South Carolina College of Pharmacy.