According to a 2007 article by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America (SHEA), the primary goal of antimicrobial stewardship is to optimize clinical outcomes while minimizing unintended consequences of antimicrobial use, including toxicity, the selection of pathogenic organisms (such as Clostridium difficile), and the emergence of resistance.1 Research indicates that up to 50% of all antimicrobial use is inappropriate. Given these findings, antimicrobial stewardship programs (ASPs) are inherently beneficial to hospitals, the patients they serve, and their communities in multifactorial ways—they hinder the development of multi-drug resistant organisms (MDROs), promote prudent use of vital antibiotics, minimize expenditures from ineffective antimicrobial treatment, reduce C. diff infection rates, and provide targeted antimicrobial treatment, all of which help improve patient outcomes.
Much of the current literature and research on establishing a pharmacy-driven ASP describe the assembly of a committee comprising specially trained infectious disease (ID) pharmacists, ID physicians, infection preventionists, microbiology technologists, and information system personnel. However, the bulk of small and/or rural hospitals may not have these resources available to initiate large-scale programs, yet they are confronted by many of the same challenges as large institutions when facing antibiotic misuse. Fortunately, establishing any type of antimicrobial stewardship program will likely reap beneficial results. Therefore, developing guidelines that ensure appropriate antibiotic use, limit or reduce overuse, and encourage conversion to oral medications will serve to reduce the potential development of MDROs, reduce harmful side effects, maintain antibiotic efficacy, and reduce costs.
Start with the Basic Tenets
At the most basic level, antimicrobial stewardship can be initiated without conscripting existing staff, requiring additional resources, or consuming large amounts of time. Likewise, initial intervention activities can be designed using readily available tools. For example, at Gerald Champion Regional Medical Center (GCRMC) in Alamogordo, New Mexico, we began our program by reviewing culture and sensitivity (C&S) reports and evaluating the type and number of antibiotics certain patients were receiving. This data analysis required no more than eight to ten minutes per day.
A pharmacy-driven ASP should focus on ensuring the patient is receiving an effective antimicrobial at the correct dose and by the most efficient route. By placing program emphasis on minimizing waste—using the minimum number of antibiotics required to effectively treat infections—and maximizing effects through the application of antibiograms and C&S results, we are able to positively influence prescription adjustments for our patients in just minutes a day.
Benefits of On-the-Job Training
While pharmacy staff buy-in and dedication is essential to a successful ASP, special training is not. On-the-job training generally provides the basis for proper decision-making, and success at this initial step will provide additional motivation and guidance to expand the scope of stewardship. With this in mind, a pharmacy-driven program can be just as successful as a multi-disciplinary, physician-led program. At GCRMC, we have assembled a modified antimicrobial stewardship team consisting of a pharmacist (not necessarily the pharmacy director), an infection preventionist, and a laboratory microbiologist. This small team also has successfully recruited individual physician champions, ad hoc, on different projects as their time allows and according to their expertise. Learning about antimicrobial stewardship through the lens of everyday work practices can have a positive effect on numerous positions and departments.
Focus on Multifaceted Education
Pharmacy-introduced ASPs tend to revolve around education and distribution of information, and these initiatives can include the following:
An additional effective method we employed was to produce pocket-sized, laminated cards with guidelines for empiric inpatient antibiotic usage and distribute them to hospitalists and attending providers (see Figure 1). We also distributed a pamphlet titled Diagnosing, Treating, and Preventing the Spread of Clostridium difficile Infection to providers within the hospital and in the community. Furthermore, we developed a chart-tagging method for C. diff infections to assist practitioners in identifying the most appropriate treatment choices based on the severity and episode number according to the latest guidelines released by SHEA.
In our experience, an IV to PO program is useful in reducing the risk of problems inherent in IV administration of medications, can ease conversion from hospital to home administration of medications, and also can decrease the overall cost of administration. Clearly, the best medications to target initially are those with good oral absorption. Proposed as an ongoing policy, review of the antimicrobial formulary and elimination of items that were either duplicates or inactive products was the first step we presented to our hospital’s medical staff committees.
To provide additional education, we produced a small booklet—Keeping it Simple: Antibiotic Choices—with an accompanying flip chart that has information about, and suggestions for, initial antibiotic therapies based on our community patterns, and divided by infectious source (See Figure 2). Our goal in providing this educational booklet is to help bridge the gap between the hospital and our community providers. It was distributed to all community physicians and providers (civilian and military) this past December and will be featured in a poster presented at the APIC national convention this June.
Use Technology to the Fullest
Creating order sets can reinforce stewardship goals by providing best practice guidelines for practitioners to follow. They also help ensure consistent care among providers and staff alike. For example, our order sets have been very useful for guiding appropriate preoperative antimicrobial selection and timing. Stop orders assist in the review of appropriate antibiotic selection once a pathogenic organism is identified.
Data mining software also has been a great tool for assessing the prevalent bacteria in our specific area and analyzing the use and effectiveness of antimicrobials against those bacteria. Infection surveillance data can provide valuable insight into the evaluation of an ASP and can be used to bolster presentations to hospital committees. In our case, we run a daily report through our electronic medical record (EMR) system that lists each patient name and any IV piggyback medications the patient is receiving. We use this report to check for appropriate renal dosing of antimicrobials as well as evaluate patients for IV to PO conversion. We also use this report to make sure patients are not receiving more antimicrobials than their condition requires.
Specialized Training Valuable, But Not Essential
At GCRMC, our pharmacists in charge of antimicrobial stewardship have not received any special training in infectious diseases. While there are many quality programs available for training in infectious disease management, stewardship programs can succeed via on-the-job training. Performing independent research and sharing information among colleagues has enabled our knowledge of antimicrobial activities to expand alongside our program. Although it took some time for our staff to become comfortable with the tenets of antimicrobial stewardship, the basic requirement for success, regardless of the method of education, is a willingness to try.
Presenting of the effectiveness of our ASP (with no significant additional costs) has been a significant selling point to our administrators. Colorful, straightforward graphs and charts have helped convey our message quickly and effectively, and has averted the need to continuously prove the value of our programs or interventions. In order to make this a 24/7 initiative, during those hours when the pharmacy is closed, e-pharmacists are available to answer questions. Furthermore, a hospital staff pharmacist is always on call if needed. GCRMC has a rather small staff of pharmacists, so we are fortunate to have a good working relationship with our providers. As with most programs that affect multiple departments and individuals, clear and consistent communication is key to the success of antimicrobial stewardship.
As a relatively small, rural facility, our ASP is organized rather differently than many of the programs described in the literature and may not be appropriate for all facility types. We began at a grassroots level with the goal of promoting prudent and appropriate use of antimicrobials, and through hard work and dedication, we have been able to demonstrate positively affected patient outcomes. Antimicrobial stewardship programs can be customized to any size facility and still provide positive outcomes within the confines of limited time, staffing, and resources. For any size facility, the success gained from initial steps can provide motivation to continue taking additional small steps. The size of a health care facility should never be perceived or accepted as an obstacle to improving patient care. As it has turned out, most of our hospitalists greatly appreciate our insight and interventions, and this has allowed us to increase the influence of our expertise. Our providers know we have the patients’ best interests in mind and by working together, we have raised the level of service we provide as a whole.
The authors would like to acknowledge and thank Dr. Susan Kellie, MD, MPH, associate professor of medicine in the division of infectious diseases at the University of New Mexico School of Medicine. Dr. Kellie received a grant to help small hospitals in the state understand and initiate antimicrobial stewardship programs. As one of the first hospitals to participate in the pilot project, Dr. Kellie’s direction and focus were invaluable.
Mary Jo Garst, MS, RPh, is a staff pharmacist at Gerald Champion Regional Medical Center in New Mexico. She received a BS in pharmacy and an MS in medicinal chemistry from the University of Iowa, and completed a hospital pharmacy residency at Harris Hospital in Fort Worth, Texas. Mary Jo worked at Yale-New Haven Hospital, Vanderbilt University Hospital, and Covenant Medical Center Hospital in Urbana, Illinois, before relocating to Alamogordo.
Marti Heinze, RN, CIC, is the infection control practitioner (ICP) at GCRMC. She received a BS from Friends University in Wichita, Kansas, an additional BS in nursing from Eastern New Mexico University in Portales, and is certified in infection control. She has worked as a nurse for over 30 years in the critical care arena, as well as in management roles before assuming her role as an ICP in 2007. Marti was awarded the recognition of a Hero of Infection Control by the Association of Professionals in Infection Control (APIC) in 2013.
Track Influential Program Data
The effectiveness of an antimicrobial stewardship program can be measured in part by collecting and evaluating data and presenting it to hospital administrators, infection preventionists, providers, and pharmacists. Presenting the following actions via charts and graphs helps convey the data and facilitates comparisons:
While the infection preventionist tracks readmissions related to infections and case managers track other readmissions, this data is not necessarily utilized to qualify the effectiveness of the ASP. However, we believe this is a great idea and plan to implement it as another improvement measure.