Case Study 2 Instructions: Please read through the case study below and consider the questions that follow. (ANSWER KEY AND RATIONALE IS DISPLAYED AT THE BOTTOM OF THIS EXERCISE)
Jonathan was treated for several days at his small rural hospital, Mountain View Hospital, for a skin infection. When he arrived at the hospital, he was unable to swallow due to persistent vomiting, so he was started on intravenous trimethoprim-sulfamethoxazole. After a few days his vomiting resolved and his skin infection improved, so he was discharged home on the IV antibiotics and set up with a home health nurse who would manage his therapy. When he went to follow up with his primary care doctor a week later, his doctor was surprised that he was using intravenous trimethoprim-sulfamethoxazole, because an oral formulation is available for this medication and it seems Jonathan would be a fine candidate to switch to oral therapy. 1. Which of the following antibiotic stewardship interventions would be most appropriate to implement in order to prevent patients from being discharged home on unnecessary IV antibiotics like Jonathan? a. Preauthorization b. An automatic stop order c. A pharmacy intervention to switch IV antibiotics to oral d. An automated alert for duplicate therapy
1. Answer: C - Rationale: A pharmacy intervention to transition patients from IV antibiotics to oral when they are able to tolerate oral medications would be most appropriate to prevent patients from being discharged home on unnecessary IV antibiotics.
Evaluation of Antibiotic Use Measures Antibiotic use can be assessed through several measures. Days of therapy (DOT) represents the total number of days that individual antibiotics are used. For example, a patient receiving three antibiotics for ten days would have a DOT of 30. When tracked regularly, this metric can be used comparatively to visualize increases or decreases in antibiotic use. 3 Defined daily dose (DDD) is an alternative measure of antibiotic use. It estimates antibiotic use in facilities by adding up the total number of grams of each antibiotic purchased, dispensed, or administered during a given period of time. 32 When compared to DOT, DDD estimates are problematic in patients with reduced drug excretion due to renal or hepatic impairment. Further, they are not appropriate for children and are not as useful when comparing data between facilities. However, when a consistent method of calculating data is used over time, DDD can be a useful measure of progress. In addition to facility-wide measures, antibiotic stewardship programs should also review data on specific antibiotics and their use in various wards across a facility. For example, when assessing interventions used to improve the treatment of community-acquired pneumonia, the antibiotic stewardship program should result in an impact on the use of antibiotics for this ailment on medical wards, rather than in surgical wards. 3 Outcome Measures Tracking clinical outcomes that measure the impact of antibiotic stewardship interventions will help to assess the effectiveness of stewardship programs. Making improvements in antibiotic use can significantly reduce rates of facility-acquired Clostridium difficile infections. Since this infection can be challenging for facilities to prevent, reducing rates of Clostridium difficile infections is an important goal of antibiotic stewardship programs. 18,19
Another important goal of antibiotic stewardship programs is to reduce antibiotic resistance. While studies that looked at the impact of improved antibiotic use on antibiotic resistance rates have shown mixed results, measuring this outcome can help facilities track antibiotic resistance rates and discover areas for improvement. In order to accurately assess antibiotic resistance, it is important to focus the measurements on pathogens that are acquired after admission to a facility, because patients in a facility are under influence of the antibiotic stewardship program interventions. Antibiotic resistance can also be monitored at the patient level; for example, monitoring what percentage of patients develop antibiotic-resistant infections has been shown to be useful. 3 Cost Savings Antibiotic stewardship programs can create significant drug cost savings, as well as savings on overall healthcare-related costs. Cost savings can help create support for stewardship programs, but facilities should be aware of the typical patterns of cost savings. Facilities that implement stewardship programs often experience significant cost savings initially, with antibiotic use and cost savings stabilizing over time. Facilities should not expect continuous decreases in antibiotic use and costs; however, continuing to support stewardship programs can maintain cost-saving levels since terminating stewardship programs can result in increased costs upon discontinuation. 33 Education A significant component of an antibiotic stewardship program is to provide regular education on antibiotic prescribing and resistance that addresses antibiotic-related issues, both on a national and local level. Using facility-specific information on antibiotic use to educate staff can help to motivate improved prescribing, especially if there are wide variations in antibiotic use patterns among similar patient care areas. 3
Education can be provided in a variety of ways: didactic presentations, newsletters, electronic communication, and flyers or posters. Cases that have been de-identified can be reviewed with providers to illustrate situations where changes in antibiotic therapy could have been made. Online educational resources are also available for facilities to use to create content. 34 Education has been shown to be most effective when combined with interventions and outcome measurements. 3 Conclusion Antibiotic stewardship programs can help prescribers and facilities 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. The seven core elements of a successful antibiotic stewardship program provide a roadmap for facilities to follow in the process of implementing their program. While antibiotics should be used appropriately for all types of infections, focusing on the therapeutic treatment of the three most common infections requiring antibiotic treatment can ensure that antibiotic stewardship programs have the greatest impact possible.
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