A Path to Better Antibiotic Stewardship in Inpatient Settings

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Antibiotics should be used only to treat bacterial infections, and should be prescribed only in doses and for durations appropriate for the patient and infection being treated. Yet the Centers for Disease Control and Prevention (CDC) estimates that up to 50 percent of all antibiotics prescribed in the U.S. are unnecessary or inappropriate, with many of them prescribed in inpatient settings.¹ All antibiotic use contributes to the proliferation of antibiotic-resistant bacteria, and more than 2 million people are infected with antibiotic-resistant organisms each year in the United States, resulting in more than 23,000 deaths.² Furthermore, antibiotic exposure increases the risk of developing a Clostridium difficile (C. difficile) infection, an illness that usually manifests as diarrhea but can be fatal in extreme cases.³ Antibiotic use also carries the risk of allergic reactions and adverse interactions with other medications.⁴

Antibiotic stewardship programs (ASPs), which are designed to minimize the harmful effects of inappropriate or unnecessary antibiotic use and slow the spread of resistance, promote the responsible use of antibiotics. ASP staff members utilize stewardship actions such as measuring a facility’s antibiotic use, providing infectious disease (ID) or pharmacy consultation for prescribers, requiring advance authorization before a physician can prescribe certain antibiotics, and tracking the results of these efforts, to encourage more appropriate antibiotic use.

Many inpatient facilities have recently begun ASPs, driven in part by new mandates. Recent federal policy proposed ASPs for acute care hospitals and long-term care facilities nationwide,⁵ and California state law now requires ASPs in acute care hospitals.⁶ Though widespread implementation of ASPs will take considerable time and effort, these programs provide innumerable benefits: They improve patient safety, minimize unintended consequences associated with all antibiotic use⁷ and can lower total medical costs.⁸

A number of tools exist to guide facilities in the development of ASPs, including the CDC publications “Core Elements of Hospital Antibiotic Stewardship” and “Core Elements of Antibiotic Stewardship for Nursing Homes,”⁹ and joint recommendations from the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America (IDSA/SHEA).¹⁰ The CDC’s guidelines suggest that ASPs include some or all of the following seven elements:

• Leadership commitment: Dedicating the necessary human, financial, and information technology resources to the program.
• Accountability: Appointing a leader who is responsible for program outcomes.
• Drug expertise: Identifying a pharmacist in charge of working to improve antibiotic use within an institution.
• Action: Implementing at least one CDC-recommended action, such as the systemic evaluation of the need for ongoing treatment of a patient with antibiotics after a set period of initial treatment (i.e., an antibiotic timeout, or a reevaluation of the drugs being used, after 48 hours).
• Education: Teaching the institution’s clinicians and relevant medical staff about antibiotic resistance and optimal prescribing habits.
• Tracking: Monitoring patterns of antibiotic prescribing and resistance within the institution.
• Reporting: Relaying information on antibiotic use and resistance within the institution on a regular basis to doctors, nurses, and relevant staff.

Fewer than 40 percent of U.S. hospitals have ASPs that include all seven core elements.¹¹ Many hospitals and inpatient facilities have stewardship programs that apply at least one of these steps, but as federal regulations take effect and the benefits of stewardship programs become more widely recognized, the number of facilities that implement ASPs with all seven core elements will probably grow.

To illustrate multiple approaches to ASPs, and provide useful examples to health care facilities seeking to establish or improve their antibiotic stewardship efforts, this report provides 10 in-depth case studies of institutions that have implemented ASPs. These facilities were selected to describe how a wide variety of institutions, with diverse financial and staff resources, have been able to implement programs that successfully demonstrated favorable economic and patient outcomes.

Key findings

Though ASPs differ in their details, these case studies reveal themes that are critical to any successful program implementation. One is the presence of an influential stewardship champion: someone within the institution who strongly believes in, and is committed to, antibiotic stewardship. St. Tammany Parish Hospital in Covington, Louisiana, for example, found that the active involvement of the ID physician who championed the cause of responsible antibiotics use was integral to the longevity of the program. This physician initially encountered internal resistance to the idea of an ASP but helped drive momentum and ensure that the program was successfully implemented.

Since implementing our antibiotic stewardship program, we’ve seen decreased antimicrobial costs and fewer C. difficile cases.Montgomery Williams, Williamson Medical Center

Another aspect evident throughout these case studies is a shared responsibility for monitoring the program and implementing new interventions. While a physician champion is critical to a program’s success, the champion alone cannot execute the program; this champion must invariably collaborate with multiple colleagues, including pharmacists, infection control staff, nurses, and hospitalists, in order to incorporate ASP elements into daily work routines. At Park Manor Nursing Home in Park Falls, Wisconsin, for example, the front-line nurses are essential to monitoring and improving antibiotic use. They investigate changes in a patient’s condition, follow up on microbiology laboratory results, reconcile and adjust antibiotics for any change in condition, and ensure that each patient receives the correct drug in the right dosage and duration. Such a model of shared responsibility, one that trains and engages all staff in ASP policies and procedures, can help employees to embrace and implement stewardship programs.

While the facilities featured in this report were successful by many accounts, some also encountered challenges, such as insufficient funding. Many of these facilities managed to implement robust programs without adding significant numbers of staff; however, each of the programs reported that additional personnel would allow their ASPs to be more effective. Sharp Villa Coronado long-term care facility in California obtained dedicated time for the stewardship pharmacist but lacked immediate resources to fund other full-time positions for either a pharmacist or physician. Instead, the ASP increased the facility’s ability to monitor antibiotic use by involving ID pharmacy students in stewardship activities. Staff of other programs also reported that dedicating at least a portion of team salaries to stewardship duties made their ASPs more sustainable and ensured the continued sustainability of a strong program in the event of key personnel loss.

The use of technology varied across programs but emerged as a common theme. For example, at the University of Alabama at Birmingham Hospital, computerized physician order entry and automated dispensing cabinets allowed for easy tracking and dispensing of antibiotics, and bedside bar-coding automatically documented and verified the administration of medication. One ASP that struggled with limited information technology (IT) infrastructure responded with labor-intensive data collection; while this was time-consuming, the program was no less successful than facilities with considerably more IT resources. These case studies demonstrate that, even for a facility with limited IT capacity, robust antibiotic surveillance and the meaningful analysis of data are achievable.

To build or sustain ASPs, many facilities had to demonstrate to administrators the benefits of stewardship programs and justify their costs. Some facilities implemented pilot projects, which were extremely useful for testing an individual intervention, quantifying cost savings, or measuring patient outcomes. In many facilities, ASPs gained support after these pilot projects showed favorable results. At Blessing Hospital in Quincy, Illinois, for example, the pharmacy conducted a three-month pilot study on the use of four antibiotics (aztreonam, tigecycline, daptomycin, and linezolid), monitoring adherence to a set of prespecified criteria for their appropriate use. The study assessed monthly savings, demonstrated opportunities for improvement in prescribing, and weighed potential clinical and economic consequences. As a result of the study, the hospital administration approved the ASP in July 2011.

This report includes, where available, results that show improved patient outcomes and trends in antibiotic use and that demonstrate reductions in adverse events and health care costs. These case studies also discuss issues related to an ASP’s development, ongoing sustainability, and future plans for enhancement. Lastly, each case study includes a “lessons learned” section, which provides useful findings for institutions that seek to establish their own ASPs. All of the information presented was provided, and reviewed by, stewardship personnel at each facility.