“Handshake Stewardship” Program Sees Drop in Antibiotic Use and C. diff Rates

Doctors at the Children’s Hospital Colorado have published their research on a new approach to antibiotic stewardship, with promising reductions in antibiotic use and rates of Clostridium difficile.

Researchers from the Children’s Hospital Colorado and the University of Colorado School of Medicine have taken a unique approach to antibiotic stewardship, cutting back on unnecessary antibiotic prescriptions and devising a strategy to help fight antimicrobial resistance.

About one-third of all antibiotics prescribed in the United States are unneeded, according to a study by the Centers for Disease Control and Prevention (CDC) and the Pew Charitable Trusts published in the Journal of the American Medical Association. This excess of 47 million antibiotic prescriptions contributes to the persisting issue of healthcare-acquired infections from drug-resistant superbugs such as Clostridium difficile. In 2011 about 722,000 people in the United states were infected with healthcare-acquired infections in acute care hospitals, and 75,000 of those patients died during their hospitalizations. Strains of antibiotic-resistant bacteria infect nearly 2 million people in the United States each year, and as a result nearly 23,000 die. The issues of healthcare infections and antibiotic resistance go hand in hand, and in response hospitals around the country are looking to improve the way they prescribe antibiotics by implementing antibiotic stewardship programs.

At the Children’s Hospital Colorado, doctors created a three-point antibiotic stewardship strategy they’ve dubbed “handshake stewardship.” In a study published in The Pediatric Infectious Disease Journal, the doctors detail the methods they used at the pediatric hospital between October 2010 and September 2014. The three features of their approach first included setting no restrictions or preauthorization for antimicrobial prescriptions. Second, all antimicrobials given to the patients were first reviewed by a team of two “stewards:” an antibiotic stewardship program physician and a pharmacist who reviewed customized patient reports. In the third step, the stewards together communicated their recommendations in-person to the team of healthcare providers during clinical rounds. The term “handshake stewardship” conveys what the authors noted was a “sealing of deals” between the stewards and their team.

During the course of the study, overall use of antimicrobials in the hospital dropped by 10.3%, with the pediatric intensive care unit reducing their use of the drugs by 14.5%. Use of vancomycin decreased by 25.7% and use of meropenem decreased by 22.2%. The researchers saw a significant decrease in the rate of hospital-onset C. difficile, which dropped by about 41%.

Two of the study’s authors, Sarah K. Parker, MD, associate professor of pediatric infectious diseases and medical director of antimicrobial stewardship at Children’s Hospital Colorado, and Amanda Hurst, antimicrobial stewardship and infectious disease clinical pharmacist at Children’s Hospital Colorado, discussed their recent findings with ContagionTM:

What are the particular challenges to implementing antibiotic stewardship in a pediatric hospital versus a general hospital?

Sarah Parker: Infections are more common in children. Previously [healthy] children suffer from ear infections, pneumonia, bone and joint infections, urinary tract infections and skin and soft tissue infections more than adults do, for example. Because these infections occur in previously [healthy] children, we use less sophisticated antibiotics, but these need review too. So we need to review more antibiotics in pediatrics to have an impact on overall use.

Amanda Hurst: Although this is true in a pediatric hospital, we share the challenges that a general hospital has as well, including finding the bandwidth to review use, build guidelines, and communicate recommendations.

Can you talk a bit about managing antibiotic resistance in young patients?

SP: Luckily, in pediatric [hospitals] we do not yet have the problems observed in adult hospitals in regards to resistant infections and Clostridium difficile infections. That said, the problem is increasing and is heartbreaking when we have difficulty treating an infection due to resistance. Our program is designed to be proactive, to try to avoid worsening resistance. While resistance has risen across pediatrics nationwide, it has not risen here, we think [this is] due to our vigilance regarding antibiotic use. We are one of the most judicious [antibiotic prescribers] in the country for a freestanding pediatric hospital.

AH: Pediatric centers that are struggling with increasing resistance are oftentimes forced to use multiple antibiotics to treat just one bug, and unfortunately those antibiotics have more side effects than the antibiotics you use to treat bugs that aren’t resistant.

What makes handshake stewardship a good approach for a children’s hospital?

SP: Most stewardship programs provide their recommendations over the phone or by a messaging system, whereas Handshake Stewardship is a more personal and interactive approach. It encourages dialogue, which is better for patients. It also allows our team to have empathy with providers in a way that traditional stewardship does not, and the providers see us as helpful, rather than as judgmental. This approach is great in a pediatric hospital because pediatricians are very dialogue- and team-oriented, but it would also be a great approach in an adult hospital!

AH: This in-person approach to feedback also offers an opportunity to provide education to new practitioners, while also commending seasoned providers on their thoughtful antibiotic choices.

The Children’s Hospital Colorado study sets an example for hospitals looking to implement an antibiotic stewardship program, which can incorporate that staff’s own expertise along with the core elements of antibiotic stewardship developed by the CDC, including leadership commitment, accountability, drug expertise, tracking and reporting, among others.