In the healthcare professions, everyone understands intellectually the value of appropriately using antimicrobials and the risk posed by the increasing numbers of multidrug resistant organisms. How much difference can a well-structured and supported antimicrobial stewardship program at one hospital make? One recent case study provides some answers.
A large community hospital in Texas first implemented an antimicrobial stewardship program (ASP) in 2001 and achieved some modest results. Interventions initially focused on conversion of highly bioavailable antimicrobials from intravenous to oral administration; discontinuation of perioperative antimicrobial prophylaxis after 24 hours, when appropriate; and restriction of certain higher risk and more expensive antibiotics. These steps produced somewhat lower pharmacy costs for antibiotics and slightly improved antimicrobial susceptibility at the hospital.1
In 2011, the hospital added an electronic surveillance and clinical decision support program to its electronic health record system to support expansion of its antimicrobial stewardship program (ASP). The ASP team, led by an infectious disease physician/hospital epidemiologist and an infectious disease pharmacist, set new goals for the antimicrobial stewardship program, including real time identification of inappropriate antibiotic prescribing, antibiotic de-escalation, bug-drug mismatches and duplicative antimicrobials.
The team received alerts from the system when certain criteria indicating potential antimicrobial misuse were met, evaluated the available information and provided feedback to the prescriber when warranted. Recommendations for changes in treatment were made via notes in the electronic health record and calls to the physicians.
In a comparison of costs and outcomes in 2010 (before the addition of the software) and in 2012, the antimicrobial stewardship program:
The hospital did not track Clostridium difficile or methicillin-resistant Staphylococcus aureus infection rates and did not find any significant changes in antimicrobial susceptibility during the year of the study.
Achieved a 90% acceptance rate for interventions, even though the ASP had no leverage to require compliance.
Experienced no adverse patient outcomes as measured by mortality, length of stay or same cause readmission.
Decreased targeted broad-spectrum antimicrobial use by 15%, primarily by achieving significant reductions in the use of daptomycin, carbapenems, piperacillin/tazobactam, quinolones, tigecycline, linezolid and vancomycin.
Saved $1.9 million in antimicrobial costs in one year.
Made more than 2000 interventions. The team most commonly intervened to recommend narrower spectrum agents in place of prescribed broad spectrum antimicrobials and reduce duration of antimicrobials to recommended number of days, but occasionally recommended higher doses, more active antimicrobials or treatment for unrecognized infections.