The Centers for Disease Control & Prevention (CDC) and the Centers for Medicare and Medicaid Services (CMS) have taken steps to slow the emergence of resistant pathogens. In March, President Obama issued a National Action Plan for Combating Antibiotic-Resistant Bacteria that called for every hospital to implement a robust antimicrobial stewardship program by 2017 that aligns with recommendations from the CDC.
As important as these steps are, it is more important to change prescribing practices and other behaviors that have become entrenched in medicine over the decades since the development of the first antibiotics, according to Debra Goff, PharmD, FCCP. Failing to change endangers the health of our patients, runs the risk of our children not having access to any effective antibiotics, and will shortly put hospitals out of compliance with federal mandates, she said in a webinar on July 22, 2015.
Antimicrobial-resistant organisms such as carbapenem-resistant Acinetobacter baumannnii and KPC-producing carbapenem-resistant Enterbacteriacea have spread across the U.S. in recent years. Focus from the media on the emergence of superbugs has increased consumer, regulator, and federal attention to the problem of antibiotic resistance.
By 2017, the National Healthcare Safety Network (NHSN) will begin tracking the number of facilities with antimicrobial stewardship policies and programs in place. The CDC will also propose new measures for hospital reporting of antibiotic use. By 2020, CMS will require all hospitals that participate in Medicare or Medicaid programs to meet Conditions of Participation that include implementation of antimicrobial stewardship programs. Hospitals will have to add electronic reporting of antibiotic use and resistance data to Stage 3 Meaningful Use programs for electronic health records to qualify for payments through the CMS Incentive Program.
Successfully meeting these requirements depends on a team approach to antimicrobial stewardship--and that team needs to understand and respect the crucial role each team member. The leader of the team must be trusted and serve as an effective champion and the team must have effective governance with clear roles and responsibilities. In addition, a successful antimicrobial stewardship team needs support from hospital leadership and to develop consequences for non-compliance on the part of the medical staff.
Within the team, the clinical pharmacist serves as the front line of stewardship to fight multidrug-resistant organisms and antibiotic abuse. Goff noted that a 2014 CDC report found that 55.7% of inpatients receive antibiotics and that 37.2% of them were inappropriate. Pharmacists need to identify and focus on key initiatives that improve the 5 Ds: correct diagnosis, correct drug, correct dose, correct duration and de-escalation.
The infection preventionist and epidemiologist coordinate facility-wide monitoring, prevent healthcare-associated infections (HAIs), assist with monitoring and reporting of resistance and Clostridium difficile infections (CDI), as well as audit, analyze and report data. Working together, these two team members can more effectively advocate for better systems for monitoring and preventing infections that may be antibiotic-resistant.
The microbiologist provides surveillance data to the team through an antibiogram and evaluate diagnostic testing to assist clinicians in selecting the therapy most likely to be effective for a specific organism. Microbiologists may effectively advocate for rapid diagnostic testing that identifies an organism in one day rather than four, enabling clinicians to appropriately treat an infection and perhaps avoid expensive complications and poorer outcomes. Use of rapid testing is also part of the National Action Plan.
Other team members include physicians, who play a crucial role as the prescribers of antibiotics and must support limiting use of antibiotics to appropriate situations supported by diagnosis. The informatics specialist helps the team track days of therapy, defined daily dose and other critical data. Nurses can advocate for cultures to confirm suspected infections and review antibiotics for appropriate indication and duration.
Who is part of your hospital’s ASP team? Do you feel prepared to meet the requirements of the National Action Plan?