Despite research showing that antimicrobial stewardship programs improve patient care and reduce antimicrobial resistance, a considerable proportion of hospitals and long-term care facilities have not implemented them. That's about to change.
While myriad forces are putting pressure on hospitals and health systems to implement antimicrobial stewardship, many feel they don't have the capability or resources to develop or manage such a program. They're too small, don't have an infectious disease physician on staff to lead an antimicrobial stewardship team or they don't have the financial resources to support a program. For some hospitals and LTC facilities, telemedicine may be the answer.
Antimicrobial stewardship is coming, and for good reason. From 20 percent to 50 percent of all antibiotics prescribed in hospitals are unnecessary, according to the Centers for Disease Control and Prevention, negatively affecting patient care by fostering resistance and leading to wasted costs. ASPs significantly reduce antimicrobial resistance, C. difficile and infectious disease-related hospital readmissions and improve infection cure rates, while saving hospitals money, notes CDC. Improving appropriate antimicrobial prescribing and reducing the number of infections reduces costs.
The World Health Organization considers antimicrobial resistance a global threat and antimicrobial misuse a significant problem in hospitals and health systems and established the first World Antibiotic Awareness Week Nov. 16-22. Meanwhile, the President's Council of Advisors on Science and Technology developed the National Strategy for Combating Antibiotic Resistant Bacteria, the Centers for Disease Control and Prevention have been pushing for hospitals and LTC facilities to develop antimicrobial stewardship programs and the Centers for Medicare & Medicaid Services is expected to require acute care hospitals to implement ASPs in order to In order to achieve meaningful progress. According to the California Antimicrobial Stewardship Program Initiative, hospitals in that state are now required to develop ASPs. Ideally, these programs are multidisciplinary, led by infectious disease physicians who have the requisite training and expertise to ensure the right drug is prescribed at the right time for the right diagnosis and duration.
Antimicrobial stewardship can be implemented via a telemedicine program: it's simply a tool, a vehicle that allows ID specialists to do what they do remotely, notes Javeed Siddiqui, MD, chief medical officer for Telemed2U, which pioneered ID telemedicine. Successful telemedicine involves the provision of healthcare over a distance using real-time audio-video technology, not just a telephone call or email, he emphasizes. Dr. Siddiqui's model received recognition from the Agency for Healthcare Research and Quality (AHRQ).
Stewardship through telemedicine: Having successfully managed ASPs via telemedicine, Siddiqui has a number of insights regarding how to ensure an effective program. The three main keys to success include:
• full commitment from leadership to the program;
• not making it primarily about cost; and
• focusing on education rather than restriction of antimicrobials.
Commitment from the highest leadership is a must, Siddiqui notes. Antimicrobial stewardship should not be a pilot project, or it's doomed to fail. In fact, the CDC's Core Elements of Hospital Antibiotic Stewardship Programs calls for a "Leadership Commitment: Dedicating necessary human, financial and information technology resources" needed to effectively implement a stewardship program. The C-suite must embrace the concept, reach out to the therapeutics committee and from there establish an antimicrobial stewardship team , which should be led by an ID physician and include representatives from pharmacy and microbiology as well as clinical care areas including hospitalists, surgery and the emergency department. In the cases where these resources may not be "in-house," there are options whereby they can be accessed remotely.
While an effective ASP may result in cost savings, it is unlikely to succeed if it is enacted solely to save money, he said. A program set up to cut costs ultimately will focus on reducing use of the most expensive antimicrobials, which isn't the most cost-effective approach. Rather, antimicrobial stewardship is about using the best drug at the most appropriate time, which ultimately saves costs as well as ensures better care. For example, vancomycin is perceived as an inexpensive antimicrobial, but it's been available since 1958; and it has become less effective as resistance continues to build. Daptomycin, while much costlier, may enable more effective treatment of patients, potentially resulting in reduced length of stay and resistance, ultimately leading to cost savings.
A successful program should not be built around restricting access to antimicrobials, but instead seek to educate healthcare workers throughout the system to make the best therapy choices. Education promotes change in prescribing behavior and is the only way to effect long-term change, which will result in understanding and long-term commitment to improved patient care, Siddiqui has found.
Setting up a successful program: Once the antimicrobial stewardship team has been established, the group should conduct a thorough review of the hospital's antimicrobial prescribing patterns and assess its antibiogram, a summary of current antibiotic susceptibilities and isolates. Armed with this knowledge, team members should work together to generate ideas for next steps, and implement a road map for those plans. As a first step, a team might choose to tackle the overuse of fluoroquinolones, a common concern. The team should hold meetings with various department heads presenting data on the problems with and extent of overuse – for example, noting that 30 percent of urinary tract infections are resistant to fluoroquinolones – and set goals for achieving a reduction in prescribing and use. The work must be ongoing. Once a hospital successfully manages its fluoroquinolone prescribing, for example, it's time to move on to sepsis, community acquired pneumonia, etc., he notes.
Information can be further disseminated throughout the hospital during grand rounds, then noon conference and in discussions with the nursing staff. Potential educational tools include pop-up menus on smart phones, PDFs displayed on the walls and cards that physicians can carry in their pockets. Education should be robust, thorough and ongoing, and not impose restrictions. Siddiqui insists physicians be given free rein to prescribe antimicrobials as they see fit. In educating patients, he also likes to provide options – for example, three alternatives to an antimicrobial that is being overused. He said he aims to induce change in 80 percent of physicians, and finds they often make the best envoys. By observing how much better their patients are doing under antimicrobial stewardship, they are more likely to organically spread the word about the program's benefits.
The ASP team should meet monthly to assess progress and next steps. A telemedicine ID specialist will conduct monthly meetings using audio and video, and quality vendors provide highly secure options that are HIPAA-compliant. In addition to regularly scheduled meetings and visits, the telemedicine ID specialist should be available for consultation at any time.
Despite Siddiqui's firm belief that physicians should not be restricted in what antimicrobials they can prescribe, he does note they also need to know that the ID physician program leader is available for consultation (whether on site or via telemedicine) and will willingly take responsibility for the drug recommended. "I tell them – your knives are dull, let me sharpen them for you. Let me be your resource and I'll take responsibility for treating this patient. I will be happy to put my name on the medical record if you follow my recommendation," notes Siddiqui.
There is a wealth of research that ASPs in general are beneficial, and Siddiqui has collected data that show telemedicine programs specifically improve outcomes. More cultures have been sent for analysis, use of targeted broad-spectrum drugs dropped and bacterial resistance to antibiotics decreased. Specifically:
• One hospital reduced its fluoroquinolone costs from $10,169 a year in 2008 to $2,359 a year, a 77 percent change.
• Another reduced the use of fluoroquinolones and piperacillin/tazobactam by 86 percent in six months. That same hospital reduced its direct antimicrobial spend by $91,500 in six months.
• In the first six months, one hospital experienced a 1.4 percent reduction in antibiotic days, coupled by a savings in antibiotic cost of $16 per patient day, translating to a total of $93,072 savings in the first six months, according to Siddiqui's IDWeek 2015 presentation. Over time, the benefits continued to grow, and in 2014 compared to the year before the program, savings in antibiotic cost grew to $43 per patient day, translating to a savings of $267,417 a year.
Changes in the antibiogram won't occur overnight, Siddiqui notes. But effective antimicrobial stewardship – e.g. treating infections appropriately – will result in dead bugs, and dead bugs don't mutate. That results in improved susceptibility to antimicrobials, the true definition of success, he said.
Antimicrobial stewardship – whether in house or through telemedicine – requires imagination and commitment on the part of leadership, and the dedication and support provided by ID specialists. But the benefits are clear – substantial improvements in healthcare outcomes and reduced costs.
Andrés Rodriguez, MBA, MSPH, is the Director of Practice and Payment Policy for the Infectious Diseases Society of America.
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