Antimicrobial stewardship programs (ASPs) are increasingly prevalent in health systems, due in large part to both the current Joint Commission standards requiring ASPs in hospitals, critical access hospitals, and nursing care centers, as well as the Infectious Diseases Society of America (IDSA) guidelines on implementing these programs.1,2 ASPs often differ in structure and focus depending on the type and size of the institution, local antimicrobial issues identified, and the depth and breadth of resources available to support the program. Regardless of the approach chosen, every ASP should collect data to evaluate the program’s impact through process and outcome measures. Despite accreditation requirements and national guidelines supporting ASPs, questions remain regarding the most effective methods of evaluating the performance of these programs.
Goals of a Successful ASP
A standardized list of validated ASP metrics does not currently exist; nevertheless, programs should consider an approach that satisfies several goals:
To meet these objectives, collaboration between the ASP team and infection control (IC) may be advantageous, as the focuses of these groups overlap; taking a collaborative approach can assist both entities in achieving their goals. In addition, working with information technology (IT) is critical for every ASP to determine how to best utilize data and the electronic health record (EHR) to run reports and track metrics. Metrics should be selected based on available ASP resources and the reporting capabilities of the clinical decision support system(s) or the EHR. Developing a positive working relationship with the microbiology lab will also support ASP efforts. Finally, in order for the ASP to experience continued success and growth, open communication and support from administration are crucial.
Track Antimicrobial Usage Trends
One of the primary ASP functions is to track changes in antimicrobial use. A common method of evaluating use is to measure days of therapy (DOT), which gauges the number of individual antimicrobial agents a patient receives on a given day. If DOT cannot be calculated, defined daily dose (DDD) may be utilized. Per the World Health Organization, DDD measures the assumed average maintenance drug dose per day as used for its main indication in adult patients.3 These measures are typically standardized by using a denominator of 1000 patient days; both DOT and DDD are effective ways to measure antibiotic consumption.
Direct pharmacy purchasing data provides a rough estimation of antimicrobial spend; however, this data does not take into account products that are expired and/or wasted through compounding processes and does not truly reflect which drugs the patient receives. In addition, price variations due to drug shortages or changes by the manufacturer should be considered. If purchasing data is utilized, it may be more meaningful to tie drug costs to doses administered. Access to a health care analytics platform for clinical benchmarking can help identify improvement opportunities. For example, an analytics tool can provide antimicrobial data including the percentage of patients receiving a particular agent, average duration of use (in days), and can compare this information to other facilities in network. This can provide useful, national benchmarking data that illustrates how certain drugs are utilized when compared to facilities of similar size or acuity.
If your facility requires that an indication be chosen when antimicrobials are ordered in the EHR, generating reports to show the most common drug(s) by these indications may provide meaningful data to the ASP. While it is important to recognize that the usefulness of this data can be limited if the prescriber chooses an incorrect indication, nonetheless, it remains valuable as an illustration of which drugs are commonly used for a particular indication. The data can also serve to facilitate directed efforts when antimicrobials are being used for an inappropriate indication or are being overprescribed for a given indication.
Identify Areas for Improvement
Internal benchmarking is key for comparing different time periods and elucidating any outliers from baseline. Reviewing data on a consistent basis can demonstrate to prescribers the trends that the ASP identifies and then allow prescribers to provide feedback. Institutions can also participate with the Centers for Disease Control and Prevention (CDC) through the Antibiotic Use and Resistance (AUR) module of the National Health Safety Network (NHSN), a central resource that provides benchmarking information for facilities to compare data at local and national levels.4 A newer metric developed by the CDC, and endorsed by the National Quality Forum, the Standardized Antimicrobial Administration Ratio (SAAR), is a risk-adjusted method to evaluate antibiotic use.4 SAAR can help analyze anti-infective utilization and compare this to national benchmarks; however, SAAR does not distinguish whether antimicrobial use is appropriate. More information about the AUR module and the SAAR is available at: www.cdc.gov/nhsn/PDFs/pscManual/11pscAURcurrent.pdf.
Once data is collected, appropriate parties should be identified to present the information to prescribers, pharmacists, hospital committees, and administrators. Dissemination can occur through a variety of forums, including antimicrobial subcommittee meetings, the pharmacy and therapeutics (P&T) committee, pharmacy department meetings, and section meetings for various hospital prescriber groups (eg, surgical services, hospitalist groups, infectious diseases, and pulmonary/critical care). Specific section meetings for a specialty group (eg, OB/GYN) permit the sharing of targeted data and allow for collaborative discussion. If there are specific prescribers or groups whose patterns demonstrate opportunities for prescribing improvement, ASP medical directors may choose to provide personal feedback to these individuals. Within these forums, the information presented should be targeted to the given audience.
Methods of reporting the data should also be considered. For example, some ASPs utilize physician “report cards” to track acceptance of ASP recommendations or to disseminate prescribing trends for targeted antimicrobials. These report cards are often shared with the prescriber names blinded so that a particular group can review trends in their overall antimicrobial use. There is also value in creating report cards for individual prescribers to demonstrate how their particular use of antimicrobial(s) compares to that of their colleagues. The personalized approach may not be suitable for all institutions or prescribers, and care should be taken to ensure the message conveyed with this data is not taken out of context by the prescriber. It is always useful to clarify that the intent of these discussions is to identify opportunities to optimize antimicrobial use, minimize resistance of targeted organisms, and improve patient safety and overall quality of care. These interactions should not have punitive intent or limit a physician’s assessment of a patient. Despite these concerns, presenting data in this format may result in meaningful conversations that ultimately improve ASP efforts.
There is no single, ideal frequency for disseminating ASP feedback to relevant stakeholders. Frequency may depend on the audience; for example, it may be reasonable to provide an annual update of key data to members of the P&T committee, given the number of items that require the attention of this group. Conversely, it may be prudent to discuss data on a quarterly basis with an antimicrobial subcommittee, since the focus of this group is primarily on antimicrobial use and it can develop quality initiative action plans.
Implement Quality Improvement Strategies
Once the essential elements of an ASP are in place, quality improvement and performance measurements must be considered. It is important to recognize that ASPs must continually evolve to address changing antimicrobial stewardship needs. An ASP should be frequently evaluated—at least annually, although preferably more often. Determine what goals have been met, review ASP-related metrics, gauge process measures that have been implemented, identify further opportunities to optimize these processes, and create new goals to move the ASP forward. Ensure that new objectives are reasonable and attainable. It is similarly important to periodically reassess how data is reported to key stakeholders and ensure that the information is meaningful and understandable.
Some institutions may have quality improvement departments in place that already track readmission rates (eg, related to Clostridium difficile infection [CDI]) and certain disease states (eg, community-acquired pneumonia). If this is an available resource, the ASP should collaborate with these individuals to determine baseline data, current trends, and opportunities for targeted interventions. ASPs can also track antimicrobial resistance patterns by comparing their institutional antibiogram over several years. Depending on the type of antibiogram, the ASP can target specific hospital floors and units and identify opportunities to focus on antimicrobial prescribing to combat identified resistance problems.
Assess Prescribing and Policy Compliance
Antimicrobial prescribing can be optimized through the use of order sets (eg, surgical prophylaxis) and institution-specific guidelines. To begin, the ASP should define what constitutes adherence versus non-adherence when using these strategies. Adherence should be measured within a defined period of time, tracking specific diagnoses, medications, and identified outcomes. Once this information is collected and summarized, it can be utilized to help facilitate process changes.
Microbiology reporting can also influence anti-infective prescribing. Depending on antimicrobial susceptibility reporting, the list of drugs available may be overly comprehensive, which can lead to prescribers choosing agents that are costly, broad spectrum, or ineffective for a particular organism. ASPs can help target prescribing by working with microbiology laboratory personnel to determine what antimicrobials may be prescribed based on the institution’s formulary, the organism, and the site of infection.
Medication-use evaluations are valuable in highlighting indication and utilization data. Formulary-restricted medication use should be tracked by individual prescriber and indication to identify whether pre-specified criteria were met. Further analysis can be performed to identify outliers and investigate the variances. ASPs can track the number of and acceptance rates for targeted clinical interventions, such as IV to PO conversion, antimicrobial de-escalation, redundant therapy, and duration of therapy. Additional data that may be collected includes antimicrobial errors (eg, wrong drug, dose, route, or frequency occurring during ordering or monitoring) and antimicrobial adverse events. This data can then be leveraged to support updates in policies, education, and/or EHR modifications.
Collaboration with the IT department is essential to effectively and efficiently collect antimicrobial use data for evaluation. In order to generate data on DOT (and DDD, if desired), it is highly likely IT resources will be needed to generate and provide these reports to the ASP. IT can also assist in generating reports that reveal antimicrobial orders with certain indications. For example, reports can be built to show only active orders for antimicrobials or to provide the ASP with information within a desired time frame (eg, 1 week) in order to review recent cases and prescribing patterns. Because the majority of data on ASP performance will require extraction from the EHR, direct collaboration with IT is vital.
In many facilities, ASPs work closely with members of IC departments, as the goals of both groups are frequently similar and target related outcomes. Some analogous initiatives include reducing surgical site infections, decreasing rates of CDI and methicillin-resistant Staphylococcus aureus infection, and improving antibiotic resistance rates. IC programs are responsible for infection surveillance and monitoring certain infection rates, such as reporting targeted organisms to NHSN. National benchmark reporting presents the opportunity to compare practices against other institutions at both the regional and the national level; this provides the ASP with an opportunity to evaluate additional data and fine tune anti-infective utilization when resistance trends are identified.
In the effort to decrease surgical site infection rates, pay attention to antibiotic choice, timing, and post-operative duration. The ASP and IC can collaborate to ensure surgical services use recommended antibiotics for each procedure, that antibiotic re-dosing occurs in the intra-operative setting (as needed), and that the length of antibiotic use is appropriate based on the procedure. IC efforts to reduce CDI can be closely tied to ASP initiatives aimed at reducing use of broad-spectrum antimicrobials. Many ASPs have documented a decrease in CDI cases in coordination with reducing the use of targeted antimicrobials, such as fluoroquinolones and cephalosporins. A combined effort can provide significant benefits for the institution and the patient. As antimicrobial exposure decreases with ASP efforts, trends in resistance rates may improve. As such, organisms would be more susceptible to antibiotics, thus reducing the number of multidrug-resistant organisms, a benefit for IC departments as well as the ASP.
Developing a positive relationship with the microbiology laboratory is crucial to success. Face-to-face interaction helps ensure that the needs of both the ASP and microbiology lab are clear. Opportunities for collaboration include optimizing susceptibility testing performed on organisms to ensure reporting of targeted antimicrobials is appropriate for the medical staff. There may be opportunities to modify or minimize the number of drugs being tested in order to provide only clinically appropriate drug choices based on the site of infection and the targeted organism. Microbiology staff may have opportunities to work with the ASP when providers request drug susceptibility testing on organisms that may be ineffective or inappropriate. The ASP can use these opportunities to engage providers with direct intervention and education. There also may be opportunities to assess the breakpoints used for susceptibility testing, which determine the organism’s interpretation of susceptible or resistant. Finally, collaboration with microbiology is necessary to evaluate and modify diagnostic platforms when new technology is implemented.
Ensure Continued Administration Support
Sustaining program growth is contingent on support from both pharmacy and hospital administration. In order to garner this support, specific goals should be tied to the metrics reported to administration to demonstrate that the ASP is achieving its objectives. Establish goals that are measurable and reasonable to attain, such as a percent decrease in DDD or DOT, or a percent reduction in use for a particular broad-spectrum or costly antimicrobial; goals and targets will be specific to each ASP. Transparency and communication of these goals and expectations is critical and should occur openly between the ASP and administration so that all parties can work together to achieve success.
There is no doubt that IDSA guidelines and Joint Commission standards have prompted many institutions to implement ASPs in recent years. While these programs often focus on implementing the required elements of effective antimicrobial stewardship—including tracking antimicrobial usage trends and reporting feedback—ASPs must also assess results, including evaluating prescribing habits, monitoring policy compliance, identifying areas for improvement, and implementing quality improvement strategies. A robust ASP continually reflects on its success and implements tactics to improve patient care.
See the CASE REPORT below for an evaluation of how Tampa General Hospital measures the performance of its ASP.
Kristen Zeitler, BS, PharmD, BCPS, co-chair of the Tampa General Hospital (TGH) antimicrobial subcommittee, received a BS in chemistry from Fairfield University in Connecticut in 2007, followed by a Doctor of Pharmacy from the University at Buffalo in 2011. Upon completion of a pharmacy practice residency and an infectious diseases specialty residency at the Hospital of the University of Pennsylvania in Philadelphia, Kristen joined TGH in 2013 to grow the antimicrobial stewardship program. Her practice interests include antimicrobial dosing and pharmacokinetics, antimicrobial stewardship, and fungal infections.
Ripal Jariwala, BS, PharmD, AAHIVP, is co-chair of the TGH antimicrobial subcommittee. Her current practice includes supporting stewardship services throughout the hospital, collaborating with ID and non-ID services, and providing education related to ID and ASP. Ripal received her BS in chemistry from the Georgia Institute of Technology in 2003 and then received her Doctor of Pharmacy degree from the University of Tennessee in 2008. Her postgraduate training included a pharmacy practice residency at the VA Sierra Nevada Health Care System in Reno, Nevada and a specialty residency in infectious diseases at the Bay Pines VA Health Care System in Bay Pines, Florida. Ripal’s professional interests include multidrug resistant organisms, stewardship-related activities, and antifungal pharmacotherapy.
Tampa General Hospital’s ASP
Tampa General Hospital’s ASP has been in place for approximately 8 years. The ASP focuses on appropriate prescribing, safety, and duration of antimicrobial therapy through evaluation of targeted antimicrobial agents. The ASP identifies hospital prescribing patterns and incorporates education and protocols to optimize use of antimicrobial agents. Additionally, the team assists with updating hospital policies involving antimicrobial agents while collaborating with various groups throughout the institution.
Since its inception, the ASP has consistently evolved to meet the needs of the institution and to ensure regulatory requirements are met. The ASP meets periodically with pharmacy administration and the pharmacy business manager to review goals and the data that has been gathered. The ASP also tracks data through its health care analytics platform for clinical benchmarking to identify trends in the most frequent anti-infectives utilized throughout the institution. The ASP meets quarterly with members of the antimicrobial subcommittee; agenda items include a discussion of data on the top 10 most costly anti-infectives and the top 10 most frequently prescribed anti-infectives used throughout the institution. This interdisciplinary group reviews the data and discusses opportunities for ASP interventions, as well as global changes to promote appropriate anti-infective use throughout the institution.
The ASP requires that anti-infective indications be included in the EHR when prescribers order broad-spectrum and/or costly medications (see FIGURE 1). An EHR report is available to assist in evaluating which antibiotics are ordered for a particular indication or by a particular prescriber (see FIGURE 2).
For example, utilizing this report, the ASP was able to determine that tigecycline, a broad-spectrum antibiotic commonly used for intra-abdominal infections, was being prescribed inappropriately for urinary tract infections (see FIGURE 3). Upon review of these cases, it was identified that tigecycline appeared on the microbiology panel for certain organisms, potentially causing prescribers to consider this agent as an appropriate therapeutic option for urinary tract infections (see FIGURE 4A). Working with microbiology, this medication was removed from urine reporting panels and the use of tigecycline subsequently declined (see FIGURE 4B). This example highlights the importance of entering accurate antibiotic indications in the EHR as well as the value of collaborating with microbiology on targeted interventions.
Each year when a new antibiogram is released, the Tampa General Hospital ASP medical director trends out gram-negative resistance for Escherichia coli, Klebsiella pneumoniae, and Pseudomonas aeruginosa. This data is reported to the P&T committee and to the medical staff. We have been able to show stable susceptibilities to these organisms for many commonly used gram-negative agents over the years.
Frequent collaboration occurs with the IC staff on numerous fronts. Recently, a group was convened to focus on decreasing CDI rates across the institution. Numerous interventions were made, which contributed to a significant reduction in CDI cases. The ASP group reviewed all identified cases of CDI; antibiotic use was noted to be a factor in many cases, frequently involving fluoroquinolones and ceftriaxone. Thus, automatic antibiotic stop dates were added to the EHR on these two drugs/drug classes to minimize extensive courses of these therapies. While automatic stop dates are not standard at Tampa General Hospital, adopting this strategy has been well received by the medical staff. As this is a newly implemented intervention, we anticipate the data moving forward will demonstrate benefit.
Future ASP goals include optimization of EHR entries related to antimicrobials and microbiology reports, implementation of rapid diagnostic technology for positive blood culture results, enhancement of allergy assessment practices, and implementation of a penicillin skin testing service. The ASP continues to promote stewardship throughout the institution, engaging with various hospital-based work groups focused on topics such as Clostridium difficile infections, MRSA infections, catheter-associated urinary tract infections, and sepsis management.
Additional information about Tampa General Hospital’s ASP is available in previous issues of PP&P:
• Optimizing Antimicrobial Stewardship (October 2015)
• Develop a Strategy for Robust Antimicrobial Stewardship (October 2017).