Multidrug-Resistant Infections: Implementing Programs for Antimicrobial Stewardship
Key considerations when choosing a treatment for gram-negative nosocomial infections include the patient’s referring facility.
Achieving antimicrobial stewardship programs’ primary goal of using antibiotics responsibly to optimize patient care and minimize development of resistant infections, requires education of and collaboration among multiple parties, including physicians, information technology (IT) specialists, hospital administrators, and patients, according to experts who participated in a Contagion® Peer Exchange panel.
Jason Pogue, PharmD, BCPS-AQID, said that implemen­tation of a successful antimicrobial steward­ship program requires support from hospital administrators and the developers and users of the stewardship policies. “If you’re going to have initiatives [and] optimize antibiotic use, you have to ultimately have support from the C-suite,” said Dr. Pogue.
Debra Goff, PharmD, said that she uses “the 5 Ds” to ensure the responsible use of antimicrobials to offset antibiotic resistance and decrease adverse events: making the correct diagnosis; selecting the correct drug, dose, and duration; and having the potential for de-escalation of therapy.
“If all you look at is antibiotic use, you’re missing the picture,” she said. “You have to have more than just the physician who might be labeled as ‘in charge of stewardship’. You need all physi­cians engaged.”
However, Dr. Goff pointed out that expecting all physicians to know the details of first-line therapy for various types of infec­tions is impractical. “I don’t expect a surgeon to know what a [carbapenem-resistant Enterobacteriaceae] is,” she said. “I tell them, ‘That’s not your job. What I need you engaged with is to engage with us and follow the guidelines. We’ll give you the rationale. We’ll give you the guidance.’ We teach them how to use the drugs responsibly, [and] then when you get the call for an antibiotic on the protected list, all the newer agents, it’s a 2-second phone call.”
TECHNOLOGY AND DATA
Sandy J. Estrada-Lopez, PharmD, said that institutions are figuring out ways to use electronic health records (EHRs) to identify which patients get infected, the type of pathogen they are infected with, and the best drug match for the pathogen. To obtain this information, some institutions use add-on systems, such as TheraDoc or MedMined, whereas the makers of the Epic system—used at her institution (Lee Memorial Health System) and others—are developing more robust modules for infection prevention and antimicrobial stew­ardship. Dr. Pogue also said that the IT depart­ment at his institution (Sinai-Grace Hospital of Detroit Medical Center) implemented an alert in the EHR if a physician attempts to order an antibiotic when a patient has recently had an organism resistant to that antibiotic.
Dr. Goff added that involvement of the hospital IT department is important for generating meaningful reports that can be used for justifying the use of expensive antibiotics for select patients or identifying patients at high risk for Clostridium difficile infection. She noted that for the latter situation, the IT department could create an alert when a proton pump inhibitor (PPI) is prescribed to a patient already on antibiotics or when 3 antibiotics are ordered for a patient already taking a PPI. “There are ways you strategize to figure out who is the highest-risk patient to get C difficile in your hospital instead of me trying to look at every antibiotic [and] every PPI,” she said. “That’s an extremely time-consuming way to approach it.”
Dr. Pogue also emphasized that providing the IT department with data demonstrating the effectiveness of the technology shows them the value of their input, which encourages them to participate in the development of antibiotic stewardship. “You’ll see reporting come up as one of these core elements of stewardship,” he said. “It’s getting that data back. We asked for a lot at my institution of our pharmacists and physicians when we revamped vancomycin dosing. They had to do a whole lot of extra steps because we thought it would be safer, and it was safer. I go to the pharmacy meeting and I say, ‘Look at these numbers.’ That gets buy-in [from the C-suite] and reinforces the importance of what you’re trying to do, which is ultimately improve patient outcomes.”
However, Andrew Shorr, MD, cautioned that stewardship is a relatively new endeavor and the effectiveness of potential protocols need to be assessed using clinical trials that compare 2 approaches. “When we start having randomized controlled trial data and we really are focused on a tool for a better kind of approach, we can actually start to apply that and say [that] the no up-front strategy is a fail, and this is the cost. But an audited feedback approach clearly offers benefits, and it’s easier to change physician behavior because that’s what this is all about with evidence.”
GOALS AND CHALLENGES
The panelists agreed that the responsible use of antibiotics to optimize care of the patient is the primary goal of an effective stewardship program, and Dr. Pogue added that activities of the stewardship program should also work to minimize the unintended consequences of toxicity, antibiotic resistance, and C difficile infection.
Additionally, educating other physicians, such as surgeons and oncologists, on the consequences of prophylactic antibiotics is important, according to Dr. Goff. “The prescribing of antibiotics is often just in case they might have an infection because they’re perceived as benign drugs with minimal risk,” she said. “Now the risk is much greater than that perceived benefit, and that’s what we’re trying to change. Stewardship has to convey that.”
Dr. Estrada-Lopez agreed that the education of other physicians on the negative consequences of unnecessary antibiotic prescribing has been relatively poor and that the lack of education is particularly evident in the outpatient setting where antibiotic use is often driven by patient request.
“Many patients want antibiotics just in case,” she said. “We’ve done a lot with education [of physicians] on ‘Use this, this is the spectrum,’ but not as much on the ‘nothing at all’ because they don’t really have an infection or really think about the total risk-benefit.”
According to the panelists, the best, and most obvious, way to avoid antibiotic resistance is to prevent infections that require treatment with an antibiotic. Dr. Shorr added that widespread promotion of up-to-date vaccinations and implementation of everyday measures in the intensive care unit to prevent infection when possible, such as elevating the bed, using orogastric instead of nasogastric tubes, and decreasing sedation, can help prevent development of resistant bacterial infections.
Hand washing is also important for preventing infection, and Dr. Shorr noted that the compliance rates are appallingly low. He stated that hand hygiene compliance among health care providers may be improved by placing hidden cameras and ensuring the hand sanitizer dispensers are refilled regularly throughout the hospital.
The panelists concluded that treating multidrug-resistant infections and promoting antimicrobial stewardship requires collaborative efforts among health care providers, patients, and hospital administrators. Dr. Estrada-Lopez said, “Working together, educating each other, and understanding how the role that we play can make a difference for patient care will lead us to the next steps in the future of decreasing antimicrobial resistance.”
Dr. Pogue added that getting patients on the correct antibiotic is a key component of stewardship and involves taking patient-specific information and local epidemiology information and using new antimicrobials judiciously. “Think what’s best for your patient as well as the hospital and get your patients on the best therapy,” he said.
Dr. Shorr concluded that collaborating with policy makers, legislators, and pharmaceutical developers will be important to increase recognition of antibiotics as a public resource that requires public stewardship. “We really need to be appealing to our policy makers and our legislators to realign incentives so that quality payments reflect quality behavior as opposed to punishments for the hospital [and] that pharmaceutical developers have legitimate reasons to risk the capital to go in and develop antibiotics that don’t pay the way chronic cancer therapies do,” he said. “All of these things need to change at a national level if we’re going to have the tools we need.”