The incidence of antibiotic-resistant strains continues to rise rapidly, making the need to combat antimicrobial resistance a global concern. For local, regional and national healthcare organisations, the ability to manage this resistance effectively starts with the introduction of an antimicrobial stewardship programme (ASP). ASPs have been proven to lower antimicrobial resistance, establishing a solid return on investment (ROI) for healthcare organisations by reducing drug-related adverse events, improving clinical outcomes and shrinking healthcare costs. By effectively setting parameters around the dose, frequency and route of administration of antimicrobials and monitoring use through both electronic and human interventions, the potential for adverse drug events (ADEs) is minimised as well as the disproportionate costs associated with them. It is an investment of resources that many healthcare experts believe is well justified for both the hospital and patient. Consider a recent initiative at a large academic medical centre targeting two antimicrobials. The end-result produced a 37% reduction in days of unnecessary therapy. Another initiative at a mediumsized hospital realised a 22% decrease in use of parenteral broad-spectrum antimicrobial use. A number of factors have been identified as contributors to the development of antimicrobial resistance. Specifically, changes in the frequency of antimicrobial use are directly related to changes in resistance, with higher rates resulting in higher incidence of resistance. A correlation has also been established between patients with healthcare-acquired infections (HAIs) and prior antimicrobial use, further confirming the association between use and resistance. In addition, the duration of antimicrobial exposure has been directly linked with the likelihood of resistant organism colonisation. To counter the increased risk of resistance and potential for popular antibiotics losing their effectiveness, a growing number of healthcare organisations are establishing ASPs for constant monitoring of antimicrobial use in an effort to limit the emergence and spread of resistant pathogens. The most successful of these initiatives feature a combination of solid clinical decision support technology and strategies for managing use, education and clinical pathways.
Goals of an ASP
Optimisation of antimicrobial use is the overriding goal of any ASP. Ultimately, it is about finding the balance between effective use and overuse – equating to managing proper selection, duration, dose, and route of administration. This process should aim to enhance clinical outcomes by improving the efficacy of identified drugs and lowering the risk of unintentional consequences associated with antimicrobial use. In tandem with improved patient care, the programme should result in cost efficiencies associated with decreased use of antimicrobials, minimised ADEs and appropriate length of stay (LOS). To successfully achieve these aims, an ASP should include methods for: • Tracking and reducing antimicrobial resistance. • Encouraging appropriate treatment patterns. • Collaboration between physicians, pharmacy, laboratory personnel and infection preventionists with best patient outcome in mind. • Ongoing and formalised education of staff and providers.
ASP implementation strategies
Fundamental to the success of any ASP is effective leadership, the lack of which can minimise any sustainable impact the programme will have. Alongside participation from key physician specialties, the antimicrobial committee should include a physician champion to lead the effort in conjunction with representation from pharmacy, infection prevention and control, microbiology and quality assurance. These individuals will come together to form the antimicrobial stewardship committee charged with such tasks as:
• Developing evidence-based guidelines for appropriate antibiotic use to slow the process of antimicrobial resistance.
• Implementing clinician-appropriate training programmes.
• Setting measurable goals, tracking resistance patterns and reporting on outcomes.
The Infectious Diseases Society of America/Society for Healthcare Epidemiology of America (IDSA/SHEA) published Guidelines for Developing an Institutional Programme to Enhance Antimicrobial Stewardship in 2007, which identified a number of strategies that reflect best practices.1 Two of the recommended approaches identified by IDSA/SHEA as ‘core’ or foundational strategies to the development of an effective ASP include formulary restriction and pre-authorisation, and prospective audit with intervention and feedback. These proactive programmes are highly recommended starting points for developing an ASP. However, organisations need to review their current practices and resource availability to determine which strategies may offer the most value or be most practical. Fully developed ASP programmes can require significant resources, but implementation of various components can be staggered and scaled over time to allow progress even if resources are limited.
Formulary restriction and pre-authorisation
By limiting use of identified antimicrobials via a direct control and approval process, the formulary restriction and preauthorisation strategy has been proven the most effective for managing use and decreasing costs. Managed by the antimicrobial stewardship committee charged with creating and enforcing guidelines for appropriate use (and often in conjunction with the Pharmacy and Therapeutics Committeee), this process requires physicians to obtain approval for specific, targeted antimicrobial agents at, or near, the time the order is written. If it is determined that a request does not fit the restrictions or guidelines, it is denied, triggering an opportunity for one-on-one education with the physician regarding appropriate use and selection of an appropriate alternative. The primary drawback to this method is that the physician community may perceive a loss of autonomy when making clinical decisions. It also requires additional resources to manage the process in a timely manner since identified personnel – most likely from the antimicrobial stewardship committee (physician and/or pharmacist) – will need to be available for consultation. A key issue here is avoiding any unacceptable delay in delivering necessary treatment to the patient. To achieve buy-in for this level of control with an ASP, healthcare organisations should seek early consultation and policy approval from the medical executive committee. When possible, notifications should be provided at the time of the order via computerised physician order entry (CPOE) applications to avoid confusion. Also, healthcare organisations should make it easy to reach the approval team by providing dedicated pagers or mobile devices. Finally, time restrictions should be established for the approval process to ensure it is efficient and not unnecessarily disruptive.
Prospective audit with intervention
As implied by the name, this strategy entails a daily (or regular) audit of targeted antimicrobial use to determine whether current therapeutic decisions and treatments have been appropriate. While it also requires establishment of an antimicrobial committee to develop guidelines for appropriate use, this strategy differs in that post-prescription audits are performed to identify problematic medication orders. When an area for potential improvement is identified, the auditor follows up with the prescribing physician to recommend alternatives and provide education. Buy-in from the physician community is often easier with this method because a perceived loss of autonomy is not experienced.
Supplemental elements and strategies
Alongside either of these foundational strategies to ASP implementation, the IDSA/SHEA guidelines also suggest supplementary elements or approaches for inclusion in an ASP. Examples include specific activities such as antimicrobial therapy streamlining and de-escalation, conversion from intravenous to oral therapy and education programmes. Education should come in the form of in-house teaching sessions, one-on-one feedback and conference presentations. Another supplemental strategy is that of developing clinical practice guidelines and pathways. While the development of appropriate antimicrobial use guidelines (as discussed with the two foundational strategies) is important, it is critical to note that antimicrobial selection is only one component in improving the management of infectious diseases. Developing treatment protocols for specific conditions, such as community acquired pneumonia, may provide the necessary structure to support more complete organisational improvement. The antimicrobial stewardship committee can serve as a multidisciplinary driver by engaging the appropriate physicians and other providers, reviewing national guidelines and taking into consideration local microbiology and resistance pattern data. Several studies have demonstrated improved clinical outcomes and decreased length of stay and overall cost with such programmes. In relation to an ASP, practice guidelines appear to positively impact antimicrobial agent use and microbial resistance as well. Randomised studies evaluating early transition from parenteral to oral therapy in the management of adults with community-acquired pneumonia have demonstrated significant reductions in length of stay (LOS) and cost of care with no adverse effect on clinical outcomes. A similar decrease in LOS, with a 52% reduction in total health care costs, was noted in the treatment of lower respiratory tract infections in children, compared with historical control subjects.1
Role of clinical decision support technology
The importance of including clinical decision support technology in the overall ASP strategy cannot be overstated. Aggregating the data needed to monitor antimicrobial resistance trends and manage the ASP process for effective decision making is a monumental task. When automated through an effective technology strategy, healthcare professionals can access intelligently filtered information to identify problematic areas and make necessary adjustments. Clinical decision support solutions can also prompt professionals that the potential for antimicrobial resistance exists. While programmes differ in complexity, the majority target key opportunities for improvement by providing real-time notification to the end-user such as:
• Immediate notification to the presciber or appropriate staff that an ordered antimicrobial is restricted. (Generally includes patient-specific demographic, diagnostic and microbiology data).
• Surveillance and notification regarding antimicrobial regimen comparisons with microbiology culture and sensitivity results; particularly where possible changes in therapy are likely needed.
• Renal function surveillance (i.e. CrCl) for all patients on antimicrobial therapies with renal elimination considerations, including agent-specific parameters to ensure proper dosing.
• Continual surveillance of patient allergy or drug-drug interaction risks with antimicrobials.
• Identification of patients with opportunities for intravenous-tooral route conversions based on both the antimicrobial agent and patient specific factors (i.e. WBC, temperature, current diet orders or PO intake).
• Surveillance for possible hospitalassociated infections.
Physicians benefit from automation to support an ASP in that they can receive alerts regarding therapeutic decisions that drive optimal antimicrobial choices for both empiric therapy and for culturebased selection.
Staying ahead of an ongoing problem
Healthcare organisations can expect that antimicrobial stewardship will remain a top priority in the industry. Findings currently suggest that pathogens will continue to become more resistant to existing antibiotics. Alongside expectations that popular antibiotics will become less effective over time, there is further concern that new antibiotic development is minimal at present. Launching an effective antimicrobial stewardship programme holds promise for effectively managing antimicrobial resistance. Healthcare organisations that employ solid leadership, process management, education and technological strategies will reap the greatest success towards enhanced patient care and cost reductions in the future.
Reference
1 Guidelines for Developing an Institutional Programme to Enhance Antimicrobial Stewardship. Clinical Infectious Diseases 2007; 44: 159-77.