Implementing a successful antibiotic stewardship program: 5 thoughts from infection control expert Dr. Ed Septimus

Hospitals must implement effective antibiotic stewardship programs to mitigate the infection risks associated with broad-spectrum antibiotic use.

While more than half of all hospitalized patients will receive an antibiotic during their stay, research shows 30 to 50 percent of antibiotics prescribed in hospitals are unnecessary or incorrect, according to the CDC.

This overuse of antibiotics threatens patient safety and promotes the spread of dangerous antibiotic-resistant infections, according to Ed Septimus, MD, vice president of research and infectious diseases at Nashville, Tenn.-based HCA Clinical Services Group.

Dr. Septimus holds more than 30 years of experience in infectious diseases. Prior to joining HCA Healthcare in 2008, he served as medical director of infectious diseases and employee health at Memorial Hermann Healthcare System in Houston for 22 years. Dr. Septimus has held leadership roles in numerous advisory groups, panels and medical societies throughout his career, most recently co-chairing the National Quality Forum's steering committees on antibacterial stewardship and patient safety.

Dr. Septimus spoke with Becker's Hospital Review about the prevalence of broad-spectrum antibiotic use, his collaboration with NQF and how hospitals can improve antibiotic stewardship efforts.

Editor's note: Responses have been lightly edited for length and clarity.

Question: Has the use of broad-spectrum antibiotics in hospitals increased in the past decade? If yes, what are the causes of this upward trend? 

Dr. Ed Septimus: While overall rates of antibiotic use in hospitals have been stable, the use of broad-spectrum antibiotics in acute care and outpatient sites has increased significantly. This distressing trend is due to increasing antibiotic resistance, as well as insecurity by physicians about what constitutes a viral versus bacterial infection and inappropriate use, both of which can spur antimicrobial resistance.

Q: How can the healthcare community address broad-spectrum antibiotic use? What are the most important areas to focus on?

ES: It is important the healthcare community attack broad-spectrum antibiotic use on multiple fronts. First, the use of better diagnostics will result in improved diagnostics certainty, which, in turn, will reduce antibiotic use. Second, more education around common clinical syndromes and diagnostics is necessary. Third, hospitals should develop approaches to measuring antibiotic stewardship, including regular audits and feedback, followed by academic detailing. Finally, hospital staff should implement a de-escalation after 48 to 72 hours — known as an antibiotic "time-out" — to avoid inappropriate use and overuse, both of which can to contribute to antibiotic resistance.

Q: What are some of the most common challenges hospitals face when trying to implement a successful antibiotic stewardship program?

ES: Some of the most common challenges hospitals face when creating or strengthening antibiotic stewardship programs stem from the absence of an approach to implementing CDC's Core Elements of Hospital Antibiotic Stewardship Programs at a practical level. To succeed, antibiotic stewardship programs need clear support from hospital leadership. Leadership commitment can be demonstrated in many ways, and the board, executive team, leadership and professional staff must all clearly articulate that commitment. Other challenges include allocating appropriate funding for staff and resources and having the right competencies among hospital staff. To be successful, hospitals must appoint the right physician or pharmacist to champion the program among staff. They should also ideally convene a stewardship committee that meets regularly and includes physicians, emergency department personnel, hospitalists, intensivists, surgeons, infectious disease specialists (if available), and representatives from pharmacy, the senior C-suite, microbiology, infection prevention, nursing and IT. Hospitals should not underestimate the importance of performance measurement and accountability, both of which can help staff identify common barriers and opportunities for continuous improvement.

Q: What resources or guidelines should hospitals consult when looking to improve antibiotic stewardship? 

ES: Some of the most widely used and scientifically rigorous guidelines include 2016 IDSA/SHEA implementation guidelines and NQF's National Quality Partners™ Playbook: Antibiotic Stewardship for Acute Care. In addition to CDC's Core Elements for acute care, other resources include CDC's Core Elements for long-term care and outpatient care. Hospital staff should address and incorporate these guidelines across the continuum of care to optimize patient safety and maintain effective antimicrobial stewardship systemwide.

Q: Can you share more about your involvement with NQF's antibiotic stewardship initiative? What is the initiative's main goal?

ES: I co-chaired NQF's Antibiotic Stewardship Action Team alongside CDC's Arjun Srinivasan, MD, to develop the NQP Playbook™. This practical resource is based on CDC's Core Elements and provides actionable strategies to help hospitals and health systems strengthen existing antibiotic stewardship initiatives or create antibiotic stewardship programs from the ground up. I also co-chaired NQF’s 2015-17 Patient Safety Standing Committee, along with Iona Thraen, PhD, from the University of Utah.

I will also serve as one of the lead faculty for NQF's Antibiotic Stewardship Workshop on Nov. 15 in Washington, D.C. This workshop builds on the NQP Playbook and CDC Core Elements to provide real-world guidance and education to help quality professionals understand common barriers to successful antibiotic stewardship programs, identify corresponding solutions from a multidisciplinary perspective, build upon existing antibiotic stewardship programs, and develop approaches to measure antibiotic stewardship and identify opportunities for improvement.

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