The Hospitalist's Role in Preventing Antibiotic Overuse

Larry Beresford


June 15, 2015

Countering Antibiotic Overuse in Hospitals

As calls grow for mandated hospital antibiotic stewardship programs, hospitalists will need to play increasing roles in advancing the safe use of antibiotics in their hospitals, according to David Rosenberg, MD, MPH, chief of the Division of Hospital Medicine at North Shore-LIJ Health System in New Hyde Park, New York.

"It's time for hospitalists to step up and see what this can do for your practice," Dr Rosenberg said in a recent interview with Medscape.

Leading infectious diseases professional groups have publicly called for the federal Centers for Medicare & Medicaid Services (CMS) to make hospital antibiotic stewardship programs a condition of participation in Medicare, noted Arjun Srinivasan, MD, associate director for healthcare-associated infection prevention programs at the federal Centers for Disease Control and Prevention (CDC). "And CMS has announced that it is exploring it as a potential regulatory action."

The need for enhanced stewardship has grown along with some bacteria's increased resistance to antibiotics, and the dwindling choices that physicians face when fighting potentially deadly infections.

The first step, said Dr Srinivasan, is adding stewardship questions to the CDC's annual hospital survey this year.

The CDC estimates that drug-resistant bacteria cause 2 million illnesses and approximately 23,000 deaths each year in the United States, and many antibiotic prescriptions, a leading contributor to resistance, are either written unnecessarily or inappropriately 20 %-50% of the time.

The President's National Action Plan for Combating Antibiotic-resistant Bacteria has called the problem a threat to national security.

California was the first state to mandate antibiotic stewardship, in 2009, with a requirement that hospitals develop quality improvement processes for the judicious use of antibiotics. In 2014, the California Department of Public Health informed providers that all general acute care hospitals in the state must adopt and implement antimicrobial stewardship programs by July 1, 2015, with a statewide collaborative established to support hospitals in these efforts.

Inaction and a National Threat

Yet nationally, only about one half of hospitals have such programs, according to a recent study in the journal Infection Control and Hospital Epidemiology.[1] The Michigan researchers who conducted the study randomly surveyed 398 hospitals and found that 48% hadn't taken the recommended step of implementing antibiotic stewardship programs, which are described as coordinated, physician-led, multidisciplinary practices to promote the most appropriate use of antibiotics in health facilities. They say that these practices can optimize treatment, reduce drug side effects and improve other patient outcomes while lowering healthcare costs and helping to curb resistance.

Dr Srinivasan urges hospitalists not to view stewardship programs as just one more government regulation. "Every hospital needs stewards to promote optimal patient care. This is the road we need to be traveling for the safety of our patients."

He adds that hospitalists, with their role in quality improvement and patient safety, are perfect partners for stewardship programs, especially in smaller hospitals that may lack infectious disease clinics or specialists. Dr Srinivasan's work with providers around the country suggests that hospitalists are willing to be engaged with the issue and to leverage their existing relationships with other professionals like pharmacists.

"It is front-line providers like hospitalists that generally use the most antibiotics, and they know where there is room for improvement," he said.

The best interventions are those that fit into the doctor's work flow, Dr Srinivasan said—"not add-ons, but process improvements that help them do their jobs better."

For example, antibiotic timeouts can be discussed several times a week during multidisciplinary rounds at specified days and times to deliberately address antibiotic use. Antibiotics are often started when patients are first admitted. "Two or three days later, we're in a better position to review what has happened: Do they have an infection, and what is it? Let's look at the patient's blood culture. Otherwise, this could get lost in the shuffle of transitions of care," said Dr Srinivasan.

"If hospitalists can see why antibiotic stewardship is a win/win situation, helping in our daily practice, helping our patients, and helping the world, they will want to make it a routine part of what they do," Dr Rosenberg said. "Where this is most relevant to hospitalists is in applying empirical antibiotic therapies, determining what's the best approach and identifying ways to reevaluate drug choices and deescalate dosages 2 or 3 days later."

Dr Rosenberg noted that the CDC is including hospitalists, among other experts, in talks about goals for improving antibiotic use in hospitals. Hospitalists seeking more information on antibiotic stewardship programs can see the CDC report Core Elements of Hospital Antibiotic Stewardship Programs.


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