Antibiotic stewardship next steps: What to do when the low-hanging fruit is gone

When the West Virginia Hospital Association started an antimicrobial stewardship collaborative in 2015 and challenged Huntington, W.Va.-based St. Mary's Medical Center to reduce antimicrobial use by 10 percent in one year, Kara W. Orwig, PharmD, the hospital's clinical pharmacy specialist in infectious diseases, was nervous.

Unlike some of the other hospitals in the collaborative, St. Mary's already had a pretty extensive antibiotic stewardship program and had already tackled the low-hanging fruit.

"I was very concerned at the start of this collaborative," she said during a June 20 presentation at Premier's 2018 Breakthroughs Conference and Exhibition in Nashville, Tenn. "We were one of the longest-standing antibiotic stewardship programs in the state. We had already eliminated so much, I really didn't know how we were going to make some of the changes these hospitals without any program at all would be able to achieve."

Dr. Orwig knew the hospital had to turn to a new opportunity to reduce antibiotic use: more rapid diagnostic testing. With a larger push from pharmacy, the hospital gradually expanded the use of methicillin-resistant Staphylococcus aureus polymerase chain reaction testing, brought in in-house procalcitonin testing, and introduced blood culture PCR and respiratory PCR testing. Dr. Orwig hoped the quicker tests would help facilitate better antibiotic de-escalation.

At the start of the collaborative, St. Mary's ranked No. 12 in terms of overall antibiotic use and No. 6 for broad spectrum antibiotic use based on baseline data. After one year, St. Mary's achieved a 22.6 percent reduction in total antibiotic use and a 26.8 percent drop in broad spectrum antibiotic use — the largest reduction among the collaborative's roughly 30 hospitals. The hospital also achieved a 44 percent reduction in hospital-onset Clostridium difficile rates over the same time period.

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