Superbug playbook: how to build an antibiotic stewardship program that works.

The overuse and misuse of antibiotics coupled with antibiotic shortages have created the perfect storm from which antibiotic-resistant infections, "superbugs," have emerged.

Pressured by new government requirements, liability exposure and a mission to deliver optimal patient care, hospitals have responded with antimicrobial stewardship programs of their own, but it is sometimes not enough.

Antimicrobial stewardship programs are simple in concept but can be very complex and difficult programs to design, implement and administer. Success requires a cultural change in how a hospital deals with, administers and tracks antibiotic use, the right team of professionals at the helm and a commitment from hospital leadership to adhere to, appropriate staff, support, and sustain an effective program.

Superbugs are the result of continued antibiotic overuse, misuse, and ongoing shortages. Unwinding the actions that created them requires an effective and actionable plan and wholesale cultural change in hospitals that rely heavily on antibiotics as a first line of defense in preventing and treating infections.

The financial toll and risk to the health of patients and the general population compelled the federal government to launch a national strategy in March 2015 to combat antibiotic resistant bacteria with specific objectives and measurable goals. This five-year initiative includes tracking the number of healthcare facilities with an antimicrobial stewardship program in place and reporting the findings directly to the CDC. The expectation is that financial penalties will be imposed on those hospitals that fail to put a program in place, and eventually on those failing to meet the aggressive infection reduction targets set out in the plan.

With so much on the line, it is increasingly imperative that hospitals not only have an antimicrobial stewardship program in place but that it be designed to meet specific goals and objectives.

A Perfect Storm

According to the Centers for Disease Control and Prevention (CDC) study, 2 million Americans a year become ill with an antibiotic-resistant infection and 23,000 dies as a result. The cost of antibiotic resistance adds an estimated $20 billion in excess costs to the healthcare system and 8 million additional days of hospitalization.

The study further found that nearly 80% of hospitals prescribe unnecessary or inappropriate antibiotics. In fact, in more than 75% of hospitals there was evidence that doctors prescribed at least one of 23 potentially unnecessary antibiotic combinations for more than two days.

Each time an antibiotic is used to treat a microbial infection that microbe builds resistance to the drug treatment. When multiple antibiotics are used, resistance to each drug builds, rendering each less and less efficacious in combating the microbe. Increasingly due to drug shortages, hospitals are turning to antibiotics of last resort, which are typically reserved for the most complex and life threatening of infections, to treat more common ones. 

Chronic antibiotic shortages and an empty drug pipeline have further exacerbated the situation.  Limited drug availability leaves hospitals with no choice but to prescribe what is on-hand, even if it isn’t the best treatment option.

It is the quintessential Catch 22: we are rapidly running out of options when it comes to treating infections, and more and more infections are becoming resistant to treatment.

Why Antibiotic Stewardship Matters

The primary objective of antimicrobial stewardship is to prevent resistance from developing in the first place. By curbing the use of antibiotics while ensuring that the patients who need them are given the most appropriate drug at the right time, a hospital can minimize the potential for drug resistance and stem the spread of antibiotic-resistant bacteria while safely and effectively delivering the care patients need.

The judicious use of antibiotics has the added benefit of insulating hospitals from antibiotic drug shortages. When a stewardship program guides decisions on prescribing antibiotics, a hospital can reduce consumption under normal operating conditions, preserving both the antibiotic and its usefulness in treating infection for when it’s imperative to patient care.

An effective antimicrobial stewardship program can reduce prolonged hospital stays and treatments, higher costs, additional doctor visits, and the chance of death associated with antibiotic infections. 

Superbug Playbook: Seven Steps to Take Now

1. Put your hospital’s best minds on the job. The Infectious Disease Society of America (IDSA) recommends that two core members of every antimicrobial stewardship team include an infectious disease physician who can champion the program to medical leadership, and infectious disease pharmacist. Ideally the team should extend to include a clinical microbiologist, information systems specialists, infection control professionals and an epidemiologist.

2. Make cultural changes and implement in a meaningful way.  The use of antibiotics is the single most important contributor to antibiotic resistance, so it only makes sense that a more conservative approach to prescribing antibiotics will begin to turn the tide on resistance. But changing requires a cultural shift in hospitals that often proves difficult to navigate.

Alter the dialogue surrounding antibiotics from "which antibiotic should we prescribe?" to "is an antibiotic necessary?" Include educational programs that keep hospital staff current on the program, and the proper protocols, procedures and processes to follow to prevent and treat an antibiotic-resistant infection. It is important to have a solid plan to implement and maintain the program. It is equally important to have a team that can implement the plan.  

3. Maintain an Antibiogram. An antibiogram is generated in cooperation with the hospital lab, infection control, and the hospital’s pharmacy. It is an essential resource in truly understanding the local susceptibility of your hospital’s population and is instrumental in identifying the most appropriate antibiotic therapy and monitoring resistance over time.  While generating the antibiogram is a collaborative effort, responsibility for it can reside with the pharmacy team.

4. Customize the program to your hospital. Unlike many disease states where similar treatments are used across the board, microbes respond differently based on the setting, population, and patients. It is a dynamic situation that requires a customized and facility-specific approach and response. Hospitals should use what they know about their hospital, the population they serve and their health profile to design a program that best protects their patients, hospital staff and community from the spread of resistant bacteria and infections.

5. Have an alternative drug plan in place. Drug shortages are commonplace, and knowing when the next one is coming and being prepared can maintain the integrity of the antibiotic stewardship program while meeting the healthcare needs of patients. Keep an eye on the supply chain, identify acceptable alternatives and take advantage of novel dosing strategies as appropriate.

6. Benchmark against the best. The federal government has established a national strategy to combat antibiotic resistant bacteria with specific objectives and measurable goals. California is already ahead of the game, and its antimicrobial stewardship mandates are the most stringent in the nation. Most of its hospitals have programs in place that can serve as a framework for other hospitals to follow.

7. Measure outcomes. Document the financial and clinical outcomes of the program to ensure sustainability and to identify modifications that may be necessary to improve its effectiveness.

An effective and sustainable antimicrobial stewardship program not only protects patients, hospital staff and the general population it protects the arsenal of antibiotics that remain available to treat and prevent infections. Taking action now is in the short- and long-term best interest of each hospital and the communities they serve.

Marvin Finnefrock serves as the vice president of clinical and purchasing services for Comprehensive Pharmacy Services. Dr. Finnefrock has direct oversight over all aspects of clinical services, the purchasing and the development of transitional care services, and his responsibilities include clinical consulting and assessment, medication safety and performance improvement programs, pharmacy ambulatory care, designing residency programs, clinical initiative and staff development programs, clinical data programs and development of cost effective patient outcomes focused programs.

Davey Legendre serves as the regional clinical director - infectious diseases for Comprehensive Pharmacy Services. Dr. Legendre designs and implements antimicrobial stewardship programs, is a regular speaker at regional and national conventions and has been published in international publications and textbooks. He also provides training to nurses, pharmacists, and physicians for various topics related to infectious diseases and antimicrobial stewardship.

The views, opinions and positions expressed within these guest posts are those of the author alone and do not represent those of Becker's Hospital Review/Becker's Healthcare. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them.​

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