Other countries have similar efforts, and a number of resources are designed to help facilities implement ASPs. To implement changes in prescribing practices, ASPs use various strategies or interventions, which are typically grouped into the following categories: formulary restrictions, audit and feedback, and provider education. There is some research about outcomes associated with each individual strategy, but usually ASPs use more than one of the above interventions, making it difficult to assess each approach individually. Approaches that are “restrictive,” (i.e., restrict high-risk antimicrobials) tend to be more effective than the “persuasive” strategies (i.e., audit and feedback, education, guidelines). There is no consensus on which interventions are most effective, and it is likely that the most effective approach may differ in different settings; effective programs are dynamic and can be adapted to facility needs. Target antimicrobials An important first step in formulary restriction is determining which antimicrobials to target for restriction. In addition to reducing the high-risk antimicrobials outlined in current guidelines, facilities may use data on regional and facility associations between CDI and antimicrobials. In one example, an ASP team examined temporal associations between antimicrobial use and CDI cases in their facility to determine which antimicrobials to target for restriction. Once target antimicrobials have been identified, ASPs may use strategies such as preauthorization requirements and removing access to the target antimicrobials. In a systematic review, Feazel et al. (2014) reported that interventions that included restricting high-risk antimicrobials (e.g., preauthorization requirements, restrictions on certain antibiotics except in unusual circumstances) were associated with the greatest reductions in CDI rates. 52 Audit and feedback include case reviews of patients receiving antimicrobial therapy, often involving a multidisciplinary team (e.g., prescribers, pharmacists, infectious disease experts, administrators) and feedback to providers, as well as audits of targeted antibiotics and other clinical measures both before and/or after treating the patient. Feedback to prescribers may include advice about switching to alternative antimicrobial agents (e.g., broad to narrow spectrum), discontinuation of antimicrobial treatment, shortened duration of microbial dose, higher or lower dose, and switch from intravenous to oral antibiotics. The latter recommendation is based on the idea that an earlier switch to oral therapy allows faster discharge from the hospital, thereby reducing exposure to CDI and drug-resistant organisms. ASPs with an audit and feedback component are widely recommended antimicrobial stewardship practices; however, ASPs based solely on an audit and feedback program showed no statistically significant reductions in CDI. One benefit of audit and feedback is that the practice itself educates
prescribers and other healthcare staff. In most studies, audit and feedback are accompanied by a staff education component, making it difficult to find associations between audit and feedback alone and CDI rates. Staff education Researchers suggest that education is important to provide context and convince physicians and other staff to participate in antimicrobial stewardship activities. Some rehabilitation physicians may be aware of the problem of antimicrobial resistance but unaware of local resistance patterns. Education programs typically include information about antimicrobial resistance, local and facility antibiogram data, treatment guidelines, and/or CDI- specific education. Educational methods can include the use of emails, pocket cards, presentations, and trainings. In an attempt to isolate the CDI associations of an educational program (as part of a multicomponent strategy), Shea et al. (2017) assessed results associated with a 3-month education campaign, then, separately, the results following a subsequent 12 months of a fluoroquinolone restriction policy. 53 The shorter education component appeared to have a significant impact, which was enhanced by the restriction policy. Compared with pre-ASP, the four hospitals experienced 48 percent and 88 percent average reductions in fluoroquinolone utilization (days of therapy per 1,000 patient days) after education and restriction, respectively. CDI rates decreased significantly from 4.0 cases/10,000 patient days pre-ASP to 3.43 cases/10,000 patient days following staff education, and to 2.2 cases/10,000 patient days following restriction. Unanticipated outcomes of ASPs One potential consideration with ASPs is that they may encourage the use of (untargeted) broad- spectrum agents and/or alternative “lower- risk” antimicrobials, which, in turn, may lead to increased resistance to the unrestricted drugs. This has been called the “squeezing the balloon” phenomenon, wherein restriction policies for use of one set of drugs leads to increased use of unrestricted alternatives, which leads to resistance. This practice runs counter to the goal of decreasing antimicrobial selection pressure. While many studies find overall reductions in antibiotic use up to 30 percent, or no significant change in overall antimicrobial use, some researchers reported increases in nontargeted antimicrobials. For example, Dancer and colleagues (2013) found that while targeted antimicrobials decreased during the ASP period, use of empiric amoxicillin and gentamicin increased, and resistance to these antimicrobials increased. 54 One of the positive outcomes of a CDI-targeted ASP can be lower rates of MRSA (methicillin- resistant Staphylococcus aureus), ESBL (extended- spectrum beta-lactamases)-producing coliform infections, and other MDROs (multidrug-resistant organisms). For example, while the primary reason for the antimicrobial restrictions and revised
prescribing guidelines in the ASP studied by Dancer et al. (2013) was to decrease CDI rates at the hospital, the researchers also found decreases in ESBL-producing coliforms following the ASP an 8.21 percent reduction. During the following 3 years, both ESBL-producing coliform infections and MRSA declined. One additional benefit (or perhaps less identified outcome of an ASP) can be an increase in the accuracy of patient diagnoses following audit and feedback interventions. Talpaert et al. (2011) found that, out of 386 interventions by the ASP team, on 75 occasions the clinicians changed the patient’s diagnosis. 55 ASPs require resources, and sometimes creative mechanisms to address resource gaps. Researchers have noted challenges with staffing limitations (when additional staff were not hired for the ASP) and a need for technical resources to track antimicrobial use. In addition, the lack of EHRs in many LTCFs can make it hard to track the exact indication for antimicrobial use. However, even with limited means, antimicrobial stewardship can produce meaningful benefits. For example, Yam et al. (2012) described the challenges of resource constraints in a small rural hospital. 56 The ASP team decided to use scheduled and as-needed consultations with a remote infectious disease specialist physician. After the ASP worked with the remote specialist for 13 months, the researchers found nosocomial CDI decreased from an average of 5.5 cases per 10,000 patient days to an average of 1.6 cases per 10,000 patient days, and antibiotic purchase costs decreased nearly 50 percent. • The CDC provides recommendations for resource-limited settings, which include: • Using nontraditional staff types to lead the ASP (e.g., infection control nurses, clinical microbiologists, or pharmacists without infectious disease training); • Using telehealth for advising on prescribing decisions; • Identifying a single priority hospital unit (e.g., ICU) in which to implement an ASP; or • Choosing and implementing a single prescribing practice (e.g., reviewing the need for antibiotics after 48 hours, or improving adherence to guidelines for empiric treatment for CA pneumonia or sepsis). Resistance on the part of providers is a major barrier to ASP implementation that is described in the literature; conversely, a facilitator to implementation is a good relationship between the ASP team and prescribers. Educating physicians and providing proof of ASP safety and efficacy are essential to garnering support. Dancer et al. (2013) found that gaining support for their ASP was challenging at the outset, especially when ASP recommendations for prescribing conflicted with previously published guidelines for a specific infection. For example, gastroenterologists initially refused to curtail ciprofloxacin prescribing for spontaneous bacterial peritonitis. After being educated about the microbiological etiology of the infection, the gastroenterologists were persuaded to change prescribing practices.
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