Antibiotic stewardship: Why we must, how we can
ABSTRACT
Improving our antibiotic use is critical to the safety of our patients and the future of medicine. This can improve patient outcomes, save money, reduce resistance, and help prevent negative consequences such as Clostridium difficile infection. The US Centers for Disease Control and Prevention (CDC) is undertaking a nationwide effort to appropriately improve antibiotic use in inpatient and outpatient settings.
KEY POINTS
- Antibiotics are fundamentally different from other medications, posing special challenges and needs for improving their use.
- Antibiotic usage in the United States varies widely among healthcare settings.
- Antibiotic stewardship efforts should focus on optimizing appropriate use rather than simply reducing use.
- Effective interventions include timely consultation on appropriate prescribing, targeting specific infections, and providing feedback to physicians.
NATIONAL ACTIVITIES IN ANTIBIOTIC STEWARDSHIP
In 2014, the White House launched a national strategy to combat antibiotic resistance,23 followed by an action plan in 2015.24 As a result, new investments have been made to improve antibiotic use, including funding for state health departments to begin stewardship efforts and to expand public awareness of the problems of antibiotic overuse. Research efforts are also being funded to improve implementation of existing stewardship practices and to develop new ones.
CMS is also exploring how to drive improved antibiotic use. In October 2016, it started requiring all US nursing homes to have antibiotic stewardship programs, and a similar requirement for hospitals has been proposed.
The Joint Commission issued a standard requiring that all their accredited facilities, starting with hospitals, have an antibiotic stewardship program by January 2017. This standard requires implementation of all the CDC’s core elements.
PROVEN INTERVENTIONS
Focusing on key interventions that are likely to be effective and well received by providers is a useful strategy for antibiotic stewardship efforts. A number of such interventions have been supported by research.
Postprescription antibiotic reviews or antibiotic ‘time-outs’
Antibiotics are often started empirically to treat hospitalized patients suspected of having an infection. The need for the antibiotic should be assessed a few days later, when culture results and more clinical information are available.
Elligsen et al25 evaluated the effects of providing a formal review and suggestions for antimicrobial optimization to critical care teams of 3 intensive care units in a single hospital after 3 and 10 days of antibiotic therapy. Mean monthly antibiotic use decreased from 644 days of therapy per 1,000 patient-days in the preintervention period to 503 days of therapy per 1,000 patient-days (P < .0001). C difficile infections were reduced from 11 cases to 6. Overall gram-negative susceptibility to meropenem increased in the critical care units.
Targeting specific infections
Some infections are especially important to target with improvement efforts.
In 2011, Magill et al26 conducted 1-day prevalence surveys in 183 hospitals in 10 states to examine patterns of antibiotic use. They found that lower respiratory tract infections and urinary tract infections accounted for more than half of all antibiotic use (35% and 22%, respectively), making them good candidates for improved use.
Community-acquired pneumonia can be targeted at multiple fronts. One study showed that almost 30% of patients diagnosed with community-acquired pneumonia in the emergency department did not actually have pneumonia.27 Duration of antibiotic therapy could also be targeted. Guidelines recommend that most patients with uncomplicated community-acquired pneumonia receive 5 to 7 days of antibiotic therapy. Avdic et al28 performed a simple intervention involving education and feedback to teams in 1 hospital regarding antibiotic choice and duration. This resulted in reducing the duration of therapy for community-acquired pneumonia from a median of 10 to 7 days.
Asymptomatic bacteriuria is often misdiagnosed as a urinary tract infection and treated unnecessarily.29–31
Trautner et al32 addressed this problem by targeting urine cultures rather than antibiotics, using a simple algorithm: if a patient did not have symptoms of urinary tract infection (fever, acute hematuria, delirium, rigors, flank pain, pelvic discomfort, urgency, frequency, dysuria, suprapubic pain), a urine culture was not recommended. If a patient did have symptoms but a problem other than urinary tract infection was deemed likely, evaluation of other sources of infection was recommended. Use of the algorithm resulted in fewer urine cultures and less antibiotic overtreatment of asymptomatic bacteriuria. Reductions persisted after the intervention ended.
Antibiotic time-out at hospital discharge
Another study evaluated an intervention that required a pharmacist consultation for the critical care team when a patient was to be discharged with intravenous antibiotics (most often for pneumonia). In 28% of cases, chart review revealed that the infection had been completely treated at the time of discharge, so further antibiotic treatment was not indicated. No patients who avoided antibiotics at discharge were readmitted or subsequently visited the emergency department.33
Targeting outpatient settings
A number of studies have evaluated simple interventions to improve outpatient antibiotic prescribing. Meeker et al34 had providers place a poster in their examination rooms with a picture of the physician and a signed letter committing to the appropriate use of antibiotics. Inappropriate antibiotic use decreased 20% in the intervention group vs controls (P = .02).
In a subsequent study,35 the same group required providers to include a justification note in the electronic medical record every time an antibiotic was prescribed for an indication when guidelines do not recommend one. Inappropriate prescribing dropped from 23% to 5% (P < .001).
Another intervention in this study35 provided physicians with periodic feedback according to whether their therapy was concordant with guidelines. They received an email with a subject line of either “You are a top performer” or “You are not a top performer.” The contents of the email provided data on how many antibiotic prescriptions they wrote for conditions that did not warrant them and how their prescribing habits compared with those of their top-performing peers. Mean inappropriate antibiotic prescribing fell from 20% to 4%.35
This is a critical time for antibiotic stewardship efforts in the United States. The need has never been more urgent and, fortunately, the opportunities have never been more abundant. Requirements for stewardship programs will drive implementation, but hospitals will need support and guidance to help ensure that stewardship programs are as effective as possible. Ultimately, improving antibiotic use will require collaboration among all stakeholders. CDC is eager to partner with providers and others in their efforts to improve antibiotic use.
