To hear experts talk about it, antibiotic resistance is a lot like climate change.
The warnings about potential consequences are dire. “I don't think some health care workers realize we are to the edge of having totally untreatable organisms. We're kind of there and I think it's going to get worse over the next few years. The pipeline is running dry,” said Henry Blumberg, FACP, professor of medicine, epidemiology and global health at Emory University in Atlanta.
And the barriers to implementing solutions—specifically, antimicrobial stewardship programs to deal with resistance—are similar, including the reluctance of those involved to change their practices to meet new requirements. “People don't like being told what they can do and can't do,” said Dr. Blumberg.
The solutions can also seem too big for individuals to tackle. “For years there was a lot of lip service…about how it was a really important issue, but almost all of the programs that were existing assumed that you were at an academic health center and you had residents,” said Gary Kravitz, FACP, an infectious disease specialist in St. Paul, Minn.
It's also easy to assume that the problem needs to be resolved by someone who is an expert. “Traditionally, hospitalists would not see themselves as the physician champion for these programs because they would automatically think it should be the infectious disease physician,” said Kavita Trivedi, MD, public health medical officer for the California Department of Public Health.
But, said the experts, it's time for these assumptions about the difficulty of change to be corrected. While leading an antibiotic stewardship program may be a little more complicated than installing an energy-efficient lightbulb, it's within the reach of hospitalists, even at the smallest community hospitals.
In fact, although academic programs may get more publicity, many community hospitals have been quietly working on antibiotic stewardship for decades, according to Dr. Trivedi, who is assisting California hospitals with their efforts. “Many of the community hospitals have been doing this for 30 to 40 years,” she said. “They just don't have the time to publish because they are actually too busy doing the work.”
In a study of 167 California community hospitals in 2010-2011, presented at the Society for Healthcare Epidemiology of America in April, Dr. Trivedi found that 45% had existing antibiotic stewardship programs and an additional 31% of hospitals were planning to initiate a program. A significant motivation for the California hospitals was a state law calling for antimicrobial oversight, but there are plenty of other reasons—including overall resistance, side effects for individual patients, and cost—for hospitals and hospitalists to pursue better stewardship, the experts said.
Reducing prescribing expenses may be the main focus in what is typically one of the first steps in launching an antibiotic stewardship program—getting the backing of hospital administration. Reducing costs has been the historic justification for stewardship in small hospitals, Dr. Trivedi explained. “Because they have been resource-limited for so long, they have actually found many benefits from developing these programs,” she said.
In addition to reducing drug expenditures, stewardship can also directly lower hospital costs by preventing expensive complications of antibiotic overuse, such as Clostridium difficile. “The most important thing is to convince your hospital administration that this program is important and that the business plan has been successful in every single setting,” said Dr. Trivedi.
Quality may be another compelling argument for gaining administrators' support. “Hospital administration is hearing about stewardship now. It's in a lot of regulatory places. It's being talked about as a core measure, or at least a reportable event,” said Elizabeth S. Dodds Ashley, PharmD, associate director for clinical pharmacy services at the University of Rochester Medical Center in Rochester, N.Y.
In addition to the administration, hospitalists interested in leading antibiotic stewardship efforts will need to meet with other interested parties. “Sit down with the pharmacy director, get microbiology in the room and whoever the infectious diseases physician leader is. Get everybody in the room to talk about, ‘Do they think there's a problem to address regarding the use of antibiotics in their hospital?’” said Dr. Trivedi.
And if there is no infectious disease physician around, don't despair. “I know a lot of hospitals don't have that resource,” said Dr. Dodds Ashley. “Many hospitals are now part of a larger health system, so maybe there's another hospital in the system that has somebody with infectious disease training that would be willing to assist you. If not in your health system, maybe somewhere in your area.”
Dr. Kravitz is one of the infectious disease physicians who has been willing to share his expertise with smaller hospitals. The large hospital where he practices shares a linked electronic medical record (EMR) with six smaller, rural hospitals. Using the EMR to review the charts of all patients on antibiotics, Dr. Kravitz and his colleagues at St. Paul Infectious Disease Associates provide stewardship advice to hospitalists at the distant hospitals.
“We're definitely able to impact in a positive way how antibiotics are used in these smaller hospitals where we have electronic oversight without actually physically going there,” he said.
Involvement of infectious disease specialists is helpful, but if it's not available, even remotely, an antibiotic stewardship program can also be effectively conducted with relatively little specialized knowledge, the experts said. “You don't have to be an infectious disease physician to understand the tenets of managing antibiotic use,” said Dr. Trivedi.
“To participate in a stewardship program, the only key ingredient is to want to do things right with antibiotics,” agreed Dr. Dodds Ashley. “Stewardship is entirely focused on the 90% of antimicrobial use that an infectious disease physician never sees or touches in most medical centers.”
Targeting an issue
Focus is another question in the start-up of a program. “The particular antibiotics that you want to target at your facility are going to be different from another facility's. Doing a little bit of legwork to understand what antibiotics are being misused at your facility is really important,” said Dr. Trivedi. That information should be retrievable from pharmacy computer systems.
The particular bacteria of the hospital should also shape stewardship program development. “If you don't have an antibiogram for your institution, you need to start there, because you can't make informed stewardship choices without knowing what your local epidemiology of infection is,” said Dr. Dodds Ashley.
The findings should then be used to shape an individualized plan. “It behooves hospitals to create institution-specific guidelines, particularly in urban settings where you're dealing with very different resistance patterns,” said Sapna Mehta, MD, medical director of the antimicrobial stewardship program at NYU Langone Medical Center in New York. “There are many national guidelines by the ID society and other professional societies for treatment of different syndromes, but for our hospital we take those into account along with our microbiology.”
Program developers should also consider what goals are achievable. “Don't be distracted by the guidelines that talk about all these great things you can do if that's going to be a huge mountain for you to climb. Start with what you can,” said Dr. Dodds Ashley.
Switching antibiotics from intravenous to oral and reducing duration of therapy are two popular areas to start, she suggested. “We've seen some community hospitals that have just focused on overuse of fluoroquinolones,” added Dr. Trivedi. “Or maybe in your facility you have a lot of antibiotics that are being prescribed for asymptomatic bacteriuria.”
Cost may also be a consideration in the selection of a campaign. “One of the major challenges is getting enough staff, funding,” said Lilian Abbo, MD, medical director of the antimicrobial stewardship program at Jackson Memorial Hospital in Miami. “Many of the interventions we try to do are the ones that don't need a lot of investment.”
The structure of interventions should also be tailored to the hospital environment, for example, whether there is an EMR or significant support from the pharmacy. “We're trying not to be too prescriptive and say to hospitals, you must use x, y and z strategy, because different strategies work in different settings,” said Dr. Trivedi about the California Antimicrobial Stewardship Program Initiative. Instead, she maintains a database of hospitals and their stewardship strategies, and offers programs advice about strategies that have worked in similar facilities.
The traditional method of antibiotic stewardship has involved restricting access to drugs that appear to be overused in the hospital. Dr. Abbo described this strategy, as it is applied at Jackson Memorial. “We have a pager or a phone number that physicians call to get approval of these restricted drugs. That gives you an opportunity to educate the doctors if you really need an antibiotic or if you need an alternative and discuss the duration of therapy.”
The advantage of this method is that you get antibiotic prescribing right from the start. The disadvantage is that the clinicians answering those phone calls and pages can start to be seen as the “antibiotic police.”
To avoid that perception, some hospitals have been experimenting with other methods. “We liberated upfront use of broad-spectrum antibiotics. That allows providers to treat empirically and then we review antibiotic use at 72 to 96 hours,” said Dr. Mehta. “That's about the time that you've gotten your data back and know what's going on with your patient. That helps us have a dialogue with the treating team about de-escalating the antibiotics,” she explained. “It's also much better received by the treating prescribers because it makes sense to them.”
Since it's based on chart review, Dr. Kravitz's telemedicine program also comes into action after antibiotics have already been prescribed. When he spots what appears to be an inappropriate use of antibiotics, he leaves a note in the communications section of the chart for the prescriber.
The phrasing of these notes can be tricky and may determine whether physicians respond by changing their prescribing or taking offense, he noted. “One does have to exercise some diplomacy when you're leaving a recommendation, so that you don't sound too heavy-handed,” he said. “You have to be nice, and say, ‘Consider this…’ so that they don't think you're trying to usurp their authority.”
Dr. Kravitz and his colleagues have also tried to increase acceptance of their efforts by giving some educational lectures at the participating hospitals. “We started with that and gradually ramped up the antibiotic stewardship program,” he said.
Education of hospital staff is a component of almost all stewardship programs. The education should make clear the reason for the efforts, Dr. Mehta noted. “We tried to be really cognizant of presenting our program before we even implemented it: We're not doing this to save the hospital pharmacy money. We're doing this to get patients the right antibiotics for the right amount of time and decrease complications.”
Dr. Abbo agreed. “We've done a campaign educating people that we're not just restricting to give you a hard time; we're restricting to help you select better what you need.” At Miami, the guideline education campaign has included pocket cards, short lectures and a website called “GotaBug” on the hospital's intranet.
When antibiotic stewards at Denver Health Medical Center in Colorado developed new guidelines on treatment of skin and soft-tissue infections, they provided education in person, online and even on the walls. “We pretty much went around and graffitied the institution with the guideline in provider work areas, to try to increase visibility,” said Timothy Jenkins, MD, assistant professor of infectious disease at the University of Colorado.
The education and repetition are necessary to overcome the traditional clinician mindset, which is antithetical to stewardship. “We've been taught in medicine over the years that the safest strategy is to prescribe broad antibiotics and when in doubt prescribe them for a long time,” Dr. Jenkins said. “The new mantra is we need to be using the narrowest spectrum of antibiotics we can and the shortest appropriate duration of therapy.”
A successful stewardship program will soon have physician champions repeating its mantra. Dr. Kravitz described how one of the hospitalists at the small hospitals he works with got excited about the issue of prescribing antibiotics for asymptomatic bacteremia. “He's constantly exhorting his colleagues not to do so,” said Dr. Kravitz.
Because prescribing patterns tend to become habits, it shouldn't be necessary to exhort physicians about the same issue for too long. “If we can keep on it for a few months, I'm hopeful that we will have changed the way that they approach patients in such a way that they use antibiotics in a more judicious fashion,” said Dr. Kravitz. “You have to do a lot of work upfront, but if people are using antibiotics more appropriately, then the amount of work you have to do every day goes down.”
To determine whether a program is leading to more judicious antibiotic use, the effects of stewardship programs should always be measured, the experts noted. “So often people come up with an intervention that's not trackable and their program dies on the vine, because they didn't look at their data sources first,” said Dr. Dodds Ashley. “Find out what data is easy for you to get and design your interventions around things you can easily track.”
Based on the results of tracking, the program can then be revised to meet current needs. “The intervention should change with time. As you teach the staff of the hospital about appropriate use, the overall use should improve and then you can focus on new initiatives,” said Dr. Dodds Ashley.
Sometimes the findings will show that a project isn't working. For example, Dr. Jenkins' program found that few physicians made use of their computerized provider order entry set for antibiotics, so future efforts will focus on other interventions.
Even if some interventions fail, he's optimistic that antibiotic stewardship as a whole is moving forward. “More and more hospitals are realizing [the benefits] and are either starting or further developing antibiotic stewardship programs,” Dr. Jenkins said. “It's gaining traction in the community is my sense.”