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Antimicrobial stewardship: Evolving mandates, growing opportunities

Justin Clark, Clinical Program Manager-Pharmacy, Fellowship Director for Pharmacy OneSource, Wolters Kluwer Health

Antimicrobial stewardship is receiving unprecedented national and international focus. Healthcare organizations that have not implemented impactful, sustainable initiatives to combat drug-resistant infections will soon have to bolster efforts as numerous U.S. regulatory initiatives converge to prioritize improvement.

In addition to national measures, the United Nations—in a rare move—recently approved a declaration addressing antimicrobial resistance. This action marks only the fourth occurrence of the UN General Assembly taking up a health issue and further substantiates the severity of the growing problem.

The reality is that inappropriate use of antibiotics is rampant in today’s hospitals and health systems. Statistics from the Centers for Disease Control and Prevention (CDC) suggest that anywhere between 20 percent and 50 percent of antibiotics prescribed in the United States are either unnecessary or inappropriate. These subpar prescribing practices exacerbate the problem of resistance, create safety risks for patients, and lead to an increase in resistant microorganisms or bacteria, which currently account for U.S. costs as high as $34 billion.

Most hospitals and health systems recognize the threat and practice antimicrobial stewardship on some level. While this is an important step forward, the scope of the problem requires standardized adoption of best practices across healthcare. Strategies must mature to encompass a formal antimicrobial stewardship program (ASP), where expectations and accountability for high performance are driven from the top.

A deeper look

In 2014, the National Action Plan for Combatting Antimicrobial Resistant Bacteria was developed following the issuance of an Executive Order by President Barak Obama. The plan directed the Department of Health and Human Services to assess current regulations and propose new implementation requirements for robust hospital ASPs based on accepted best-practice models such as the framework suggested by the CDC.

In response, the Joint Commission and Centers for Medicare and Medicaid Services (CMS) have both taken action to ensure formal ASPs are implemented and backed by the right resources and competencies. Beginning January 1, 2017, eight new Joint Commission antimicrobial stewardship performance standards for hospitals, critical access hospitals and nursing care centers go into effect. Expanding upon its existing 15 standards that “relate to” antimicrobial stewardship programs (ASPs), the additional requirements include:

  • Leadership-driven antimicrobial stewardship as an organizational priority;
  • Education of staff members and licensed independent practitioners;
  • Education of patients and families as needed regarding appropriate use of antimicrobial medications;
  • Establishment of an antimicrobial stewardship multidisciplinary team that includes infectious disease physician, infection preventionist, pharmacists and other practitioners
  • Program design that encompasses the CDC’s seven core elements of ASPs in hospitals or nursing homes;
  • Use of organization-approved multidisciplinary protocols in the program;
  • Data collection, analysis and reporting related to the program; and
  • Evidence of action taken on the opportunities for improvement identified through the program.

While not yet finalized, CMS issued a proposed rule in June that will also require hospitals to meet new performance criteria, calling for deployment of formal ASPs that work in tandem with infection control programs. Sections pertaining to ASPs focus on two aspects: organization and policies of the programs and leadership responsibilities. Specifically, the rule lays out the following components:

  • Implementation of a hospital-wide ASP;
  • Evidence of coordinated efforts across hospital departments including infection prevention and control, quality, medical staff, nursing services and pharmacy.
  • Identified leadership at all levels; and 
  • Antibiotic use protocols and a system to monitor antibiotic use

High performing ASPs

Antimicrobial stewardship is a national priority, plain and simple. In truth, the premise of ASPs aligns with evolving value-based care models and healthcare’s Triple Aim in that it promotes higher quality care delivery and lower costs. Yet, many hospital and health system executives lack the expertise and resources needed to implement a high-performing ASP, especially in light of the many competing regulatory initiatives requiring attention.

Those health systems that have mature, impactful ASPs increasingly find that a two-pronged strategy designed around advanced surveillance infrastructures and workflow governance produces the desired return on investment. In fact, one large Texas-based community hospital decreased broad-spectrum antimicrobial use by 15 percent in one year through this model, representing a cost savings of $1.6 million.

In terms of workflow governance, the CDC suggests that hospitals implement seven core elements of effective hospital ASP including:

  • Leadership Commitment: Dedicating necessary human, financial and IT resources.
  • Accountability: Appointing a single leader (physician ideally) responsible for program outcomes.
  • Drug expertise: Appointing a single pharmacist leader responsible for working to improve antibiotic use.
  • Action: Implementing at least one recommended action, such as systemic evaluation of ongoing treatment need after a set period of initial treatment.
  • Tracking: Monitoring antibiotic prescribing and resistance patterns.
  • Reporting: Regular reporting information on antibiotic use and resistance to relevant staff.
  • Education: Educating clinicians about resistance and optimal prescribing.

Advanced surveillance technology addresses the need for early identification and proactive prevention. When a foundation of real-time, actionable patient information exists to power clinical decision-making, the potential of circumventing adverse events is much greater. Surveillance technology is uniquely positioned to power ASPs this way through ongoing aggregation and tracking of patient data. Rules-based infrastructures provide intelligently-filtered alerts to clinicians when antimicrobial issues surface. Also, real-time notification of orders for restricted antimicrobials, drug-bug mismatch, comparisons of antimicrobial regimens, renal function surveillance, patient allergy or drug-drug interaction risks and possible hospital-acquired infections speed effective response.

While oversight of antimicrobial processes has historically rested with clinical and quality professionals, heightened regulatory focus necessitates that the C-suite take the lead. Antimicrobial resistance is a global, regional and organizational concern that requires shared responsibility from all stakeholders along the continuum. As such, healthcare executives must implement high-performing, sustainable ASPs to combat the growing epidemic of resistant organisms.