Expanding the Antibiotic Stewardship Team Can Lead to Greater Adoption of Practices
There is value in leveraging the contributions of nurses, laboratorians, and informaticists in antimicrobial stewardship.
Antimicrobial stewardship programs have become standard across hospitals in the United States in response to a 2014 recommendation from the Centers for Disease Control and Prevention (CDC).1 Although progress has been made in optimizing use of antimicrobials since their implementation, many programs face resource and personnel constraints that limit their capacity. A 2021 cross-sectional study including 192 hospitals found that 55.9% of patients received antibiotic regimens that did not adhere to recommended practice.2 This suggests that there is room for improvement in optimizing antimicrobial usage. Traditionally, the bulk of antimicrobial stewardship activities is handled by infectious disease–trained physicians and pharmacists; however, leveraging other health care professionals is recommended by the CDC and has been shown to reduce unnecessary antibiotic use as well as modifiable risk factors for infection.1 Although there are numerous health care professionals who may contribute significantly to antimicrobial stewardship, this article aims to explore the potential roles of nurses, laboratorians, and informaticists in supporting optimal antimicrobial use.
ANTIBIOTIC STEWARDSHIP IS PATIENT ADVOCACY AND HARM PREVENTION: INVOLVING NURSES
The CDC and the American Nurses Association (ANA) advocate for involving registered nurses in antimicrobial stewardship initiatives.3 Nurses spend more time with patients than any other health care team member, conducting frequent assessments and building strong rapport with patients. Critically, nurses serve as the primary interface between patients and other health care services. For example, whereas pharmacists review and verify medications, nurses administer them; whereas providers order lab testing, nurses obtain those tests.
In this role, nurses influence when and whether lab tests are sent, the need for antimicrobial therapy, and the assessment of antimicrobial allergies. All these aspects have been instrumental in helping to identify and reduce catheter-associated urinary tract infections (CAUTIs) and central line–associated bloodstream infections (CLABSIs).4 Nurses often see themselves as patient advocates on the medical team. A survey of 61 nurses, nurse managers, and infection preventionists revealed that nurses perceive their involvement in antimicrobial stewardship initiatives as harmonious with their role as patient advocates.5
Specifically, nurses most favored the following practices: questioning the need for urine cultures, ensuring proper culturing techniques, and encouraging conversion of intravenous antibiotics to oral formulations when appropriate. Although few studies have evaluated the effectiveness of antimicrobial stewardship initiatives led by nurses, the available data suggest that such initiatives have achieved considerable success. A pilot study conducted at a community regional medical center assessed the efficacy of novel, nurse-driven, biweekly antimicrobial stewardship rounds, in which bedside nurses assessed the presence of and need for antimicrobials, as well as various infectious risk factors, such as acid-suppressant medication and catheter presence and duration, after receiving training from infectious diseases pharmacists and advanced practice providers.6 The investigators found a significant reduction in antibiotic, acid suppressant, and urinary catheter use, along with a trend toward reducing Clostridioides difficile infection incidence after implementation of the initiative. The authors identified several essential elements for the successful implementation of this pilot project. Nurses were able to execute meaningful interventions while supported by a peer expert, a nurse coordinator with antimicrobial stewardship training, and a multidisciplinary team.
Furthermore, key stakeholders from the staff and hospital administration were receptive to the initiative due to its alignment with institutional objectives. Additionally, the involvement of a nurse champion and program coordinator allowed for implementation of the pilot with minimal disruption to nursing workflows. In the context of increased nursing burnout since the COVID-19 pandemic, it is vital to be cognizant of added burden on nursing workload when electing to implement antimicrobial stewardship initiatives. Antimicrobial stewardship teams must be vigilant in aligning with established nursing priorities, while providing adequate support to avoid the perception of increased burden on staff. Many nurses participate in antimicrobial stewardship on an informal basis; however, formalizing these practices by creating a structure in which stewardship is explicitly addressed is necessary to effectively utilize their insight and contributions. Despite the recommendations from the CDC and the ANA for the inclusion of nursing in antimicrobial stewardship efforts, adoption remains rare.7 Additional investigation into implementation and outcomes must be conducted for further realization, optimization, and practical implementation of nurse-driven antimicrobial stewardship.
DIAGNOSTIC STEWARDSHIP IS ANTIMICROBIAL STEWARDSHIP: INVOLVING LABORATORIANS AND INFORMATICISTS
Laboratory professionals are experts in lab-based testing and specialize in a variety of areas, including clinical microbiology and molecular diagnostics. They provide critical and timely diagnostic information to enable the identification and management of infectious diseases. Informaticists craft and maintain the electronic medical record, the interface between clinicians and patients.
Given their fundamental roles in health care delivery, these health care professionals, as part of antimicrobial stewardship teams, can execute systemic interventions, facilitating appropriate identification of infections (and noninfections) through “diagnostic stewardship.”8 Diagnostic stewardship involves the modification of decisions made during the microbial diagnosis process and encompasses guidance regarding selection of appropriate laboratory tests and cultures related to infectious diseases, as described by Morgan et al.8 Diagnostic stewardship can mitigate costs to the hospital and health care system as a whole and can lead to the prevention of inappropriate antimicrobial prescribing. In selected situations, diagnostic stewardship has demonstrated superior efficacy in minimizing improper antibiotic utilization compared with conventional antimicrobial stewardship approaches.9
Asymptomatic bacteriuria (ASB) is a prevalent condition in which bacteriuria is present in the absence of systemic or localized symptoms of a urinary tract infection (UTI). At any given time, 5% to 15% of healthy individuals will have ASB. This prevalence increases to 30% to 60% of older patients residing in long-term care facilities and is present in nearly every patient with a chronic indwelling urinary catheter.10
Studies have demonstrated that the treatment of ASB does not prevent the development of UTI in most patient populations, and therefore the Infectious Diseases Society of America recommends against screening and treating asymptomatic nonpregnant healthy individuals, including those with chronic indwelling catheters.11,12 Despite these recommendations, antibiotic prescribing among these patients remains high. A study conducted in hospitals participating in the Michigan Hospital Medicine Safety Consortium identified that of the 2461 patients presenting to the emergency department and found to have ASB (positive urine culture, no symptoms of urinary tract infection), 74.4% received antibiotics for a median duration of 6 days.13
These results indicate an association between positive urine culture and antibiotic prescription in asymptomatic patients. Logically, targeting a reduction in urine culture obtainment may decrease unnecessary antibiotic prescriptions in patients with ASB. This is an opportunity for collaboration with informaticists, microbiologists, and laboratorians. A multisite study examined the impact of the implementation of a new urine culture order set within the electronic health record (EHR) mandating clinicians to specify the indication for urine culture, including the identification of UTI symptoms. Following the implementation of this order set, the number of urine cultures performed decreased by 40.4%.14
These results demonstrate the value of integrating the expertise of health informaticists, in collaboration with antibiotic stewardship programs, to design and implement similar EHR order sets that support diagnostic stewardship and, by extension, antimicrobial stewardship. An additional example of incorporating health informatics include utilizing lab reporting “nudges” (accompanying text reported along with a laboratory result) within the EHR to help guide clinicians toward empiric broad-spectrum antibiotic de-escalation. A commonly employed approach to minimize unnecessary methicillin-resistant Staphylococcus aureus (MRSA) antimicrobial coverage is the utilization of MRSA nasal polymerase chain reaction (PCR) tests to determine colonization status of patients being treated for pneumonia in a hospital setting. It has been demonstrated that this assay has a negative predictive value for MRSA pneumonia exceeding 99%.15 Although the use of a MRSA nasal PCR to rule out MRSA pneumonia has become prevalent in the past decade, its use in implicating MRSA in other infection types is still evolving. By restricting the utilization of MRSA nasal PCR tests to authorized indications and employing “nudges” reinforcing the assay’s utility, it is possible to mitigate avoidable costs and unwarranted de-escalation. At one academic center, it was found that implementation of a pharmacist-driven MRSA nasal PCR protocol led to significant reductions in median vancomycin duration and was associated with a cost avoidance of $40.33 per vancomycin course when accounting for drug, PCR test, and serum drug level monitoring costs.16
Another study assessed the efficacy of adding language specifying the absence of MRSA and Pseudomonas aeruginosa to respiratory culture results that were previously reported as “commensal respiratory flora” and found 5.5-fold increased odds of de-escalation after implementation, further reinforcing the efficacy of nudges in antimicrobial stewardship.17 In addition to these tools, proposed diagnostic stewardship initiatives include the development and use of multistep C difficile testing protocols with the authority of the microbiology lab staff to reject samples in which patients recently received laxatives, as well as restrictions on diagnostic tools that carry a low-test probability in specific situations.18 Developing relationships with relevant parties who have a shared interest in antimicrobial stewardship is vital in gaining support from other departments, particularly those focused on cost reduction or improving rates of CAUTI, CLABSI, or C difficile infection among inpatients.
CONCLUSION
Many opportunities exist for health care professionals to contribute to antimicrobial stewardship. This review focused on the evidence to support the role of the microbiology lab and informaticists in diagnostic stewardship to reduce inappropriate antibiotic and lab use, as well as the impact that nurses can have on reducing unnecessary antimicrobial prescriptions and infectious-related risk factors. Antimicrobial stewardship program leaders are strongly encouraged to expand their team roster to include the expertise of microbiologists, informaticists and nurses, among others. As the saying goes: Teamwork makes the dream work.
References
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