• Ensuring staff have sufficient time to complete antibiotic stewardship activities. • Relevant training and staff education. • Ensuring all appropriate groups contribute to and support antibiotic stewardship activities. • Financial support. This support enhances the impact of antibiotic stewardship programs. Further, these programs often pay for themselves through cost savings on antibiotic purchases as well as indirect costs. 2. Accountability: A leader or group of leaders should be designated to be responsible for managing the antibiotic stewardship program and its outcomes. Due to their formal training in infectious diseases, physicians are often designated leaders in successful stewardship programs. Approximately 60% of hospitals in the US have found success utilizing a co-leadership model, with a physician and pharmacist leading the antibiotic stewardship program. Larger facilities that have successful antibiotic stewardship programs often hire full-time staff to develop and manage the program; smaller facilities typically develop alternative arrangements, such as part time or off-site managers. 7,8 Typical roles in an antibiotic stewardship program include: 3 •
3. Drug expertise: A pharmacist should be designated as a co-leader, responsible for working toward improving antibiotic use. Pharmacists trained in infectious disease are ideal candidates for this position, as this training has been shown to improve antibiotic use. 9,10 4. Action: Antibiotic stewardship programs should identify interventions that can address facility issues with antibiotic prescribing and work to implement these interventions. Common antibiotic stewardship interventions include: 3 • External reviews of antibiotic prescribing should be conducted by an antibiotic use expert, in a process known as prospective audit and feedback. This occurs after the antibiotic has been prescribed. Some facilities find success reviewing treatments prescribed for common conditions, such as urinary tract infections, while others choose to review complex antibiotic courses. Providing feedback to physicians in face to face meetings can improve effectiveness of this audit. • Preauthorization, or required approval that must be obtained prior to utilizing certain antibiotics, can create an opportunity to receive assistance with antibiotic choice and dosing. The choice of antibiotics that will require preauthorization should be made after consulting with providers and should focus on improving empiric drug use, and not on drug costs. In order for preauthorizations to be utilized effectively, there must be staff on hand to approve authorizations in a timely manner to avoid delays in treatment. While preauthorization has been shown to be less effective than prospective audit and feedback, they are often effectively used in conjunction to ensure antibiotics are both initiated and continued appropriately. • Treatment guidelines that are facility-specific should also be prioritized to establish clear recommendations for antibiotic selection and duration. Guidelines should incorporate national recommendations as well as local antibiotic susceptibilities, patient populations, and formulary options. 5. Tracking: Antibiotic prescribing and resistance patterns should be monitored in order to determine the impact of interventions and identify improvement opportunities. Tracking can be divided into three categories: 3 • Antibiotic use measures such as days of therapy per days present at the facility can help identify antibiotic overuse. • Outcome measures such as reductions in Clostridium difficile infections can assess the impact of antibiotic stewardship measures on patient outcomes. • Quality improvement process measures can provide feedback on specific antibiotic stewardship measures, such as identifying areas where additional staff education would be beneficial.
Introduction The introduction of antibiotics into the practice of medicine has transformed the lives of millions of people. Infections that were once lethal are now easily treatable, and medical advances have been able to move forward through the use of antibiotics. Unfortunately, approximately 30 percent of all antibiotics administered in hospitals in the United States have been deemed either unnecessary or inappropriate. 1,2 The misuse of antibiotics has contributed to increases in the rates of Clostridium difficile infections and adverse reactions to antibiotics, as well as the development of resistant strains of bacteria. The Centers for Disease Control and Prevention estimates that approximately 35,000 deaths annually are caused by antibiotic- resistant organisms. 3 Inappropriate prescribing of antibiotics is considered a significant public health and patient safety issue. An increasing amount of evidence supports the use of “antibiotic stewardship programs” to enhance the treatment of infections and decrease adverse events associated with the use of antibiotics. Antibiotic stewardship programs can help prescribers improve patient safety and the quality of patient care by improving infection cure rates, decreasing the rate of treatment failures, increasing the rate of correct antibiotic prescribing, reducing hospital rates of antibiotic resistance and Clostridium difficile infections, as well as increasing cost savings. 4-6 Antibiotic Stewardship Seven Core Elements of a Successful Hospital Antibiotic Stewardship Program Since medical decision-making regarding antibiotic use is complex and variable, implementation of an antibiotic stewardship program must be flexible and tailored to the type of setting it covers. Successful implementation is possible with defined leadership and a coordinated multidisciplinary approach. 3 Core elements of a successful hospital antibiotic stewardship program include: 3 1. Commitment from leadership: Financial, human, and information technology resources must be dedicated to the program for successful implementation and continuation. The CDC goes further to specifically identify strategies considered a “priority” for hospital leadership. These priority actions largely emphasize allocation of appropriate time, funding and other resources to support staff in effectively managing the program. Leadership support can take a number of forms: 3 • Formal statements that a facility supports efforts to monitor and improve antibiotic use. • Information on antibiotic stewardship duties in job descriptions and annual performance reviews.
Prescribers and department leaders: It is vital that prescribers of antibiotics are engaged and supportive of antibiotic stewardship programs. Infection preventionists and epidemiolo- gists: These roles are typically involved in fa- cility-wide monitoring and infection prevention measures; auditing, analyzing, and reporting data; monitoring and reporting resistance and trends; educating staff; and implementing plans to improve antibiotic use. Quality improvement staff: Optimizing antibiotic use plays a role in medical quality and patient safety. Laboratory staff: These personnel can help ensure tests are utilized properly and results are reported to prescribers in a timely manner. They also play a role in guiding empiric antibiotic therapy by creating and interpreting the antibiogram, a report that summarizes a facility’s cumulative antibiotic resistance. Information technology staff: Responsible for integrating antibiotic stewardship protocols into existing workflow through the creation of action prompts to review antibiotics in specific situations, facilitating the collection and reporting of data, implementing clinical decision support, and embedding relevant information at the point of care. Nurses: Play a role in ensuring cultures are performed prior to starting antibiotics when possible. They can also routinely review antibiotics and prompt discussions on antibiotic treatment, durations, and indications.
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