What can hospitals do to take a stand against antibiotic resistance? Inside the University of Chicago Medical Center's stewardship program

Picture a world where antibiotics don't work. That's the world Jennifer Pisano, MD, imagines and works to keep at bay every day.

Recent media coverage has helped bolster visibility for the growing menace of antibiotic resistance, but Dr. Pisano, medical director of the University of Chicago Medical Center's antibiotic stewardship program, says she's been on red alert for some time now.

"It's been an emergency for years," Dr. Pisano says. "Once it's been an emergency for so long, you get used to it. You have to get creative."

As medical director of an antibiotic stewardship program for a large academic medical center, Dr. Pisano oversees how the organization handles antibiotic prescription, drug management, drug shortages and education of both the public and University of Chicago's physician base on best antibiotic practices in the face of growing bacterial resistance. The program comprises a dedicated physician and pharmacist team who specialize in infectious diseases and take a unique approach to stewardship, including active social media campaigning and data collection to provide physicians with feedback on their prescribing habits.

And their efforts are paying off — University of Chicago Medical Center physicians adhere to the stewardship program's antibiotic prescription recommendations about 95 percent of the time.

"We get called the antibiotic police sometimes, or people think we just want to put road blocks in front of physicians and other providers who want to have autonomy with how they use antibiotics, but that's certainly not the case," Dr. Pisano says. "It's important to impress upon people there are a lot of misconceptions about antibiotic stewardship and the ultimate goal of any stewardship program is patient safety."

Dr. Pisano spoke with Becker's Hospital Review about what hospitals can do to prevent the spread of resistance, how antibiotic stewardship has changed in the last decade and using social media to educate patients.

Note: Responses have been lightly edited for length and clarity.

Q: Has the antibiotic stewardship program at University of Chicago Medical Center changed since antibiotic resistance has become a more visible issue?

Dr. Jennifer Pisano: Absolutely. We've been doing some kind of stewardship for over 10 years here but our program became official in 2010. The first couple years were really about drug restriction and education, about why it was important. It's kind of switched gears a little bit to a more quality and safety focus now. It's become easier in the past couple of years to get resources and buy-in from patients since there's been more talk about stewardship. A few years ago, if a patient came in with a respiratory virus and you didn't want to give them an antibiotic, they would be hesitant. Now it's become easy to discuss why we are concerned about resistance and why we want to save antibiotics.

We've seen improvement on the physician side as well; people are increasingly recognizing that it's important. We've been doing what we're doing for a while now and a lot of it depends on physician relationships and trust that our recommendations are coming from a good place — not just cutting costs or restricting antibiotics, but a consideration for patient safety.

Q: What are the main tenets of the antibiotic stewardship program? Have they remained the same since its inception?

JP: The two kind of main tenets of stewardship are antibiotic resistance and prospective audit and feedback. Before the program officially started, there was a prospective audit and feedback system in place where a designated person would monitor clinicians who were giving these restricted or protected antibiotics. Their cases would be followed and depending on what was going on with the patient, they'd see if we could narrow the antibiotic or change it from the restricted agent and help the provider along in doing that.

In 2010, we created a charter and got buy-in from administration for salary support for a physician and pharmacist pairing to kind of run the program. Since then, we've been building on the previous restriction and feedback and building out our program. We have a number of safety programs where we monitor blood culture results and give feedback to physicians to see whether the antibiotics they're using are appropriate, or if they can change them. We've continued adding on and growing the main tenets as we get more used to dealing with certain issues.

Q: What has the clinician reaction been to having a team monitor their antibiotic prescriptions?

JP: People know us by now and know what to expect on the other end of the line when they call us. I think accepting our recommendations involves building a relationship with us and knowing that we have the best intentions. Of course, patient safety is our number one goal. We do have times when physicians are steadfast in their approach and we have had to find ways to meet in the middle at times.

In those instances, we reinforce the fact that everything we do and all of our recommendations are evidence-based. If there's guidance in the literature, we can do some educating and in turn the specialty physicians can educate us. We perform periodic evaluations for any intervention we make to make sure we're getting the desired effects, so once physicians are able to see that process, we're able to give them a lot of data on their antibiotic use too. It's really a give and take and over time we're able to work together and find the best road to take.

Q: Your antibiotic stewardship program has a strong social media presence, is that important for patient buy-in and education?

JP: Our Facebook page and Twitter feed were created in 2014 as part of a social media project we undertook to educate our internal medicine residents. As part of that, we ended up doing a lot of education and outreach all over the country. I think patient education and lay public education is enormously important because these are the people we're treating and we're going to see more and more stewardship going from inpatient to outpatient hopefully in the next couple of years.

In terms of patient education, it's really about creating a partnership and devising a plan because the patient will decide which antibiotic they do or don't want to take — if we recommend they shouldn't take an antibiotic but they really want it, they can just go to the next place and they'll get it. So I think patient education is very high on the list of important jobs of hospital systems and stewardship programs in making sure people understand we aren't abandoning them. If we don't think antibiotics are necessary for a patient who wants them, there are a lot of ways to meet in the middle with them. I think as long as you're communicating about it, they're usually happy to hold off on a prescription.

Q: Do you think there is a bare minimum protocol hospitals should have in place for antibiotic stewardship?

JP: Restriction alone is not stewardship. I really think you need a dedicated person, or even better a dedicated team, to handle stewardship. I think a dedicated physician and pharmacist partnership that has time to just focus on stewardship is very important. The pharmacist is an antibiotic expert terms of in mechanism and use and handles a lot of the day-to-day activities in restriction and monitoring along with the physician. It's really important to have that physician there for clinical correlations, to be able to reach out to other physicians and affect change. An infectious disease specialist is ideal for that role.

Q: Do you think hospitals can affect significant change as awareness about antibiotic resistance grows?

JP: I think you have to look at the hospital itself and also look at a regional model of stewardship. We have patients who are contained with our hospital system, they visit the same clinics and facilities and we're able to follow their paths and monitor how we're using antibiotics. But outside of that, in the real world, especially in agriculture, bacterial resistance is everywhere. And I think over time we're going to see stewardship branch out more and more from just the hospital to the nursing homes to clinics and other hospitals in the region.

We use a kind of grid called an antibiogram to look at all of our bacteria on one axis versus our antibiotics on the other to determine what our level of resistance is. I think over time the antibiograms from different areas are getting more and more similar, we're getting more and more data that there is a lot of community-acquired resistance.  Stewardship at specific hospital institutions is just one place to start, but over time we need to look more broadly to control the spread of resistant organisms.

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