ID Docs Best Poised to Lead Antimicrobial Stewardship Programs

Ricki Lewis, PhD

February 15, 2018

The eclectic expertise of infectious disease (ID) specialists uniquely qualifies them to lead antimicrobial stewardship programs (ASPs), according to a joint statement from the Infectious Diseases Society of America, the Pediatric Infectious Diseases Society, and the Society for Healthcare Epidemiology of America.

"Antimicrobial stewardship is a rapidly growing field concerned with antibiotic misuse and development of drug resistance and adverse effects of drugs. The paper grew out of a need to demonstrate who is going to take responsibility for the goals of these programs," John Lynch III, MD, medical director of the Harborview Medical Center Infection Control, Antibiotic Stewardship, and Employee Health programs in Seattle, Washington, told Medscape Medical News. ASPs oversee drug selection, dosing, duration of therapy, and route of administration, according to a 2012 statement from the Infectious Diseases Society of America, the Pediatric Infectious Diseases Society, and the Society for Healthcare Epidemiology of America. Such efforts improve patient outcomes and counter the evolution of drug resistance.

The new statement, published online February 12 in Clinical Infectious Diseases, is in response to a proposed rule that the Centers for Medicare & Medicaid Services submitted in June 2016 that calls for antibiotic stewardship and infection prevention and control programs in all hospitals that receive federal funding. It is also a response to meet standards of the Joint Commission, an independent, not-for-profit organization that accredits and certifies nearly 21,000 healthcare programs and organizations in the United States.

The ASP leadership role transcends both routine patient care and hospital epidemiologist duties and fits the unique skill set of ID specialists, write Belinda Ostrowsky, MD, from Montefiore Medical Center, Albert Einstein Medical Center in Bronx, New York, and colleagues. ID physicians have leadership experience within their institutions and with public health agencies, experience treating complex infections, and deep knowledge of microbiology, antimicrobials, and the link between informed prescribing and quality measures.

In an ASP, an ID physician leads multidisciplinary teams that include physicians, pharmacists, nurses, and microbiologists in guiding and implementing controls of antimicrobial use in all healthcare settings.

Measures of improved patient outcomes include reduced hospital admissions for infections and treatment duration, lower antimicrobial costs, fewer drug–drug interactions and treatment-related adverse events, and lower rates of antimicrobial resistance. Common goals are lowering incidence of Clostridium difficile infections and sepsis associated with central lines.

The Joint Commission published an antimicrobial stewardship standard, effective from January 1, 2017, that requires ASPs in hospitals, critical access hospitals, and nursing care centers. Yet, almost half of acute care hospitals do not have ASPs, and the fraction of other healthcare facilities, such as dialysis centers and outpatient clinics, without ASPs is even higher.

In addition, only 48% of hospitals surveyed have instituted all seven core elements described previously by the Centers for Disease Control and Prevention:

  • leadership (ensures adequate funding, personnel, and information technology),

  • accountability (single leader),

  • drug expertise (pharmacists on teams),

  • action (implementing evidence-based recommendations),

  • monitoring (tracking prescribing practices and local drug resistance patterns),

  • feedback (reporting on antimicrobial use and resistance), and

  • education (on antimicrobial prescribing practices and local resistance patterns).

When asked about the low proportion of programs including all elements, Lynch said, "Requiring a hospital to have an ASP is fairly new. The only regulations are from the Joint Commission and the Centers for Medicare & Medicaid Services proposed rule." Hospitals may only be asked whether they have an ASP or not, rather than a probe of meeting the seven core elements. "But ASPs are probably going to see increasing requirements and maybe even public reporting of antibiotic use data," he added.

Antibiotic stewardship is disproportionately uncommon in rural hospitals, critical access hospitals, and small community hospitals, but telemedicine is helping to deliver ID physician expertise. "Here in northwest Seattle, we have a telemedicine program with almost 30 critical access hospitals with a weekly meeting with case discussions, review of local data, and sharing guidelines," Lynch said.

Case Vignette Highlights Benefits

The new statement presents an "initial" and "modified" clinical vignette to contrast the benefits of having an ID physician in charge of an ASP.

A 60-year-old man with type 2 diabetes presents in an emergency department with likely sepsis. Blood cultures are taken and broad-spectrum antibiotics begun. He is admitted to the intensive care unit, and the next day, rapid-identification PCR reveals distinct bacterial species, which prompts the pharmacist to advise substitution of a more targeted antimicrobial. But she has no supervising ID physician, and the patient's physician, uncomfortable with advice from a nonphysician, continues the original, broad-spectrum drug.

The patient develops Clostridium difficile colitis, then a second bloodstream infection with a resistant microorganism. After a 3-week hospital stay, he is transferred to a long-term care facility for continuing care. There, he transmits C difficile to his roommate, delaying that man's discharge.

In the modified vignette, the initial antimicrobial is prescribed empirically, based on educational materials and an antibiogram that the ASP team developed (a summary of antimicrobial susceptibilities of local bacterial isolates). The polymerase chain reaction findings trigger implementation of a protocol the ID physician developed that calls for immediate review of the prescribed antimicrobial. When the patient's physician ignores the pharmacist's suggestion to narrow the antibiotic therapy, the ASP ID physician leader steps in and convinces the patient's physician to switch the drug. The patient improves rapidly and is discharged to home before the week is out. The hypothetical roommate at the long-term care facility avoids his costly diarrheal fate.

The report also offers examples of successful ASPs. Among the campuses of Montefiore Medical Center in Bronx, New York, for example, the first 2 years of the ASP reduced antimicrobial use 10% to 15%, saving more than $900,000, and reduced C difficile infection up to 40%.

Lynch concludes by saying, "Antimicrobial stewardship means a broad-reaching program that involves patients, their families, and specialists including nurses and pharmacists as well as physicians. The optimal people to lead these programs are infectious disease physicians, because they work across all of those silos."

One coauthor reports compensation from the NIH Antibacterial Resistance Leadership Group. Another coauthor reports compensation for speakers bureau participation for Merck and Allergan and for research support from Diatherix. Another coauthor consults for Biomerieux, Biofire, Merck, and GlaxoSmithKline. The other coauthors report no conflicts of interest.

Clin Inf Dis. Published online February 12, 2018. Abstract

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