Antimicrobial Stewardship in the Digital Age
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Antimicrobial resistance is on the rise nationwide. Despite years of warnings about the dangers of antibiotic overuse, and despite ongoing research and development of ever more powerful antimicrobial agents, the bugs appear to be winning, albeit stealthily.
In January, the CDC announced the September, 2016 death of a Nevada woman from a carbapenem-resistant Enterobacteriaceae (CRE) infection resistant to 26 different antibiotics - the entire US arsenal. The microbe which led to the woman’s death may have been acquired in India as the patient had been hospitalized there repeatedly for complications related to a femur fracture.
Though hers is an extreme case, infectious disease specialists and those on the front line of the fight against so-called “superbugs” say it may be a harbinger of things to come if we stay on the current course.
“In 2013, 23,000 people died as a direct result of antibiotic overuse, according to CMS,” says infectious disease specialist Jawad Nazir, MD, Medical Director for Avera’s Antimicrobial Stewardship Program (ASP). “Another 14,000 die of C. difficile infections brought about by antibiotic overuse. This is especially disturbing when you consider that the CDC estimates up to 50 percent of antibiotic use is unnecessary.”
Patients infected with resistant organisms have significantly higher rates of morbidity and mortality. Those who survive such an infection have longer hospital stays, as do patients who contract C. diff, the most common cause of diarrhea in hospitals and a risk factor for death in people over 55.
“The nature of this infection is that it keeps on coming back,” says Dr. Nazir. “It is very hard to treat and can be very bad. There is a huge cost to this.”
Beyond the pain, suffering and expense it creates for patients, unnecessary or inappropriate antibiotic use also has the potential for significant economic impact on healthcare institutions; for many hospitals, antibiotics account for a third of the pharmacy budget.
Pressured to Prescribe
“Most experts in the field will say that we’re losing the battle,” says clinical pharmacist Brad Laible, PharmD, pharmacy co-leader for Antimicrobial Stewardship at Avera. “There have been some new antibiotic agents in the last decade that give us more options, but they have not been able to keep up. If we continue to persist in our current practices, we are destined for failure.”
Such dire predictions are not news to most medical professionals, who have been hearing about the dangers of antibiotic overuse for years. So why is the problem continuing to worsen? And why are there so many unnecessary prescriptions?
“There is still a lot of pressure placed on providers to prescribe antibiotics,” says Laible. “Patients are often upset. They have taken a day off work, they may be losing money. They feel like they should get something out of it. They are expecting a prescription for an antibiotic.”
And, as often as not, they get it. A case in point is Zithromax, one of the most frequently prescribed antibiotics in the US. Although the number of Zithromax prescriptions outmatches most other agents, Laible says it is not recommended as a first-line treatment for any infection. “Providers are just overly comfortable with prescribing it,” he says. “It is a bad practice.”
Setting a New Standard
As more and more cases of CRE and extended-spectrum beta-lactamases (ESBL) resistance continue to render large groups of antibiotics ineffective, the Joint Commission announced in January a new Medication Management standard that addresses antimicrobial stewardship in hospitals, critical access hospitals and nursing homes.
Among other things, the new standard requires that critical access hospitals establish an antimicrobial stewardship multidisciplinary team that includes an infectious disease physician and a pharmacist with expertise in antibiotic use. The program is to make antimicrobial stewardship an “organizational priority” and must demonstrate “leadership commitment” in the form of financial and human resources, accountability, tracking of prescribing patterns, reporting, strict formularies, and education of providers and patients.
But what happens to smaller hospitals that may not have an infectious disease specialist, a specialized pharmacist, or the resources to create a true Antimicrobial Stewardship Program?
For Avera, the answer was clear - utilize its extensive existing telemedicine infrastructure to provide the expertise its smaller institutions need to get a handle on antibiotic use and comply with the new standard.
“What we have done is develop a model for implementing this in small, rural hospitals using technology and the resources we have,” says Dr. Nazir whose team has been doing infectious disease consultations via telemedicine since 2003. “It just made sense to use this same system to help other hospitals run their own ASP.”
Pharmacists at Avera facilities in Yankton, Pierre, Mitchell, Aberdeen, Parkston, Brookings, Marshall (MN), Worthington (MN), and O’Neill (NE) have been trained to recognize potentially problematic cases of infection in the hospital and present them via telemedicine to Avera infectious disease doctors at a daily virtual meeting.
Dr. Nazir says these pharmacists watch for the same red flags that Avera McKennan pharmacists like Brad Laible and his team are constantly monitoring - patients on two or more antibiotics for more than 48 hours, those who may be on the wrong antibiotic, any patient with a C. diff infection, and others.
“I get a list of the people who have cases to present,” explains Dr. Nazir. “The patient record comes up on my screen and I can see the medication list, the progress notes, etc. It is as though I am actually at the hospital looking at the computer with the pharmacist.”
After review, Dr. Nazir (or one of his four infectious disease partners who share the ASP duties) may recommend deescalating the antibiotic dose, changing medicines, or even stopping a particular antibiotic (the most common recommendation). The local pharmacist then relays that information back to the prescribing doctor. After more than 1,000 of these ASP consultations, Nazir says about 95 percent of the recommendations have been accepted, compared to a national average of just 80 percent.
‘Front End’ vs. ‘Back End’ Approaches
Reviewing cases of infection after an antibiotic has been prescribed - known as prospective audit and feedback - is an example of what Laible calls a “back end” approach to antimicrobial stewardship. It is the same approach followed since 2011 by the Sioux Falls VA Health Care System, where infectious disease specialist Veronica Soler, MD, is the Clinical Director of the ASP and Andrea Aylward, PharmD, is its Pharmacy Director.
“This is one of the core elements of our antimicrobial stewardship,” says Aylward, who conducts formal stewardship rounds twice a week and participates in a formal sit-down review panel with Dr. Soler and others weekly. “We go through every patient, discuss their antibiotic, look at the lab results and cultures and decide if they are on the right drug at the right dose. We recommend changes in about 15 percent of cases.” Afterwards, they track compliance, which is typically over 90 percent.
“The ultimate goal is to have less resistance,” says Dr. Soler. “We want susceptible, easy-to-treat common bacteria that respond to narrow antibiotics that may have been used for 20 or 30 years and not have to turn to the expensive new antibiotics that drive so much of the resistance.”
On the “front end” of antimicrobial stewardship are things like formularies laying out which antibiotics are encouraged and which ones are off-limits except on the recommendation of an infectious disease doctor. “Maintaining and updating the guidelines on antibiotic use in our computer system is a big part of our job,” says Aylward. “When guidelines change, we make sure our system is up to date with the CDC.”
Another important front-end element of an ASP is an antibiogram, a spreadsheet created by microbiologists and pharmacists each year that illustrates patterns of use and resistance over time in a particular region or institution.
“We might have a bacteria that is common in the urine and one year 90 percent of that bacteria might be susceptible to a particular antibiotic then the following year we can look at the antibiogram and see that it has dropped to 85 percent and the following year it may have dropped to 80 percent,” says Dr. Soler, who may consult the antibiogram before prescribing to make sure she’s using the best drug.for the job.
A change in resistance patterns is an indication that intervention, such as the one Avera staged around the drug levofloxacin (Levaquin), may be needed.
“People used to joke that it was ‘Vitamin L’,” says Laible. “At Avera, we were using enough of this drug that we had created some resistance. But through provider education and dissemination of the antibiogram, we have seen more than a 50 percent reduction in the amount of Levaquin being used, which resulted in a dramatic change in susceptibility to that agent again.”
Similar progress has been made at Avera in recent years to turn around antibiotic resistance in E. coli and pseudomonas and to reign in a CRE outbreak in Aberdeen. The VA reports a reduction in C. dff and Methicillin-resistant Staphylococcus aureus (MRSA) infections.
“Awareness is the key,” says Laible.
Turning the Trend Around
In an effort to support healthcare institutions like Avera and the VA in their ASP efforts, the CDC has created educational materials for providers to share with their patients. Additionally, through the CDC’s National Healthcare Safety Network, an infection tracking system, hospitals can not only get a clearer picture of their own antibiotic usage as well as that of others.
“It has been helpful for us to be able to see ourselves and our own usage patterns each month and compare them with hospitals in Minneapolis or Omaha,” says Dr. Soler, whose hospital has one of the lowest rates of antibiotic utilization in the region. “This is a very valuable too.”
In the end, Laible says no tool will be a substitute for hospitals and providers taking a harder line in the fight for safe and effective healthcare.
“We know that there are stewardship approaches that do work, but it can mean tough decisions and difficult conversations with patients and even colleagues sometimes,” says Laible.
“We do not need to reinvent the wheel,” agrees Dr. Nazir. “Our goal is to implement the interventions that have been proven effective in many other hospitals for decades. So far, we have done about 20 percent of what needs to be done in this area. Many specialties are continuing to overprescribe. There is room for lots of improvement.”