Published in the December 2008 issue of Today’s Hospitalist
AS HOSPITALS STRUGGLE to combat antibiotic resistance, a growing number are launching stewardship programs to ensure that physicians not only choose the right antibiotics, but use the drugs appropriately. Hospitals are exerting more control over physicians’ antibiotic choices, relying on restricted formularies and a host of technological tools to keep physicians on a tighter prescribing leash.
That approach, however, raises obvious concerns among physicians who worry that their prescribing decisions will be subject to constant oversight. Those concerns have in turn led to questions about how antibiotic stewardship programs should be used to change physician behavior.
One hospital has implemented a program that not only improved the susceptibility of certain antibiotics from 20% to 47%, but has maintained those gains for several years. According to the clinical pharmacist who co-directs the program, the effort has succeeded in part because the program relies on a light touch when intervening in physician prescribing.
Maine Medical Center, a tertiary center and teaching hospital in Portland, launched its stewardship program in 2001 after a randomized controlled trial held at the center got administrators’ attention.
That study, which was published in the Aug. 11-25, 1997, Archives of Internal Medicine, found that when patients were initially treated with parenteral antibiotics, physicians were able to change half of those regimens after only three days. Because that move saved money, the hospital OK’d a stewardship program targeting community-acquired pneumonia.
The program centerpiece is a computer decision-support tool that asks physicians the following five questions:
1. Where does the patient come from? A drop-down menu allows doctors to indicate home, long-term care or acute-care transfer.
2. Is the patient going to the ward or the ICU?
3. Is the patient at risk for pseudomonas?
4. What risk factors does the patient have for chronic high-dose steroid dependency? The drop-down list includes such factors as COPD or a history of MRSA.
5. Is the patient allergic to beta-lactams? Once physicians answer the questions, the system automatically blacks out all inappropriate antibiotic choices. The system also highlights the antibiotics it recommends that physicians prescribe.
Physicians can override those selections, but Robert Trowbridge, MD, a hospitalist who chairs the pharmacy and therapeutics committee, says that doesn’t happen often. When physicians do override the system, he explains, it’s typically because the patient has unusual allergies or a specific contraindication to a recommended antibiotic.
A soft restriction strategy
One thing that distinguishes Maine Medical’s stewardship efforts is what Rob Owens, PharmD, the clinical pharmacist who co-directs the program, calls “the human touch.” While the program helps guide antibiotic choices, Dr. Owens says it avoids taking a “cookbook approach.”
The program, for instance, steers clear of a strategy embraced by other hospitals that restricts “everything but cefazolin” and forces physicians to page someone every time they want to prescribe an antibiotic.
Instead, Dr. Owens says, the program restricts only five antibiotics, “and they’re soft approvals, so you don’t need a consult. You just need to call the program.” And while many programs rely on checklists and standing orders to guide prescribing, Dr. Owens, who works exclusively on the stewardship program, opts for a personalized “backend approach.” Instead of over-ruling a prescription, he or his infectious diseases colleague “Patricia Stogsdill, MD “will talk over the dose or regimen with the ordering physician. What he calls physician “interventions” are often subtle suggestions to de-escalate therapy or try an antibiotic weaning trial.
Common prescribing errors
Drs. Owens and Stogsdill review every patient’s antibiotic regimen five days a week, averaging 160 patients a day. Since the program’s debut, the two have made 4,500 antibiotic interventions.
Dosing errors are physicians’ most common mistake, Dr. Owens says. “I assumed that patients would be on too high of a dose,” he explains. “But it turned out to be a wash: Approximately half need an increase in dosing regimen, which was a surprise.”
When intervening, Dr. Owens might suggest that physicians move to more narrow antimicrobials; switch from IV to oral therapy; or choose another antibiotic based on resistance patterns.
Like many other facilities in the U.S., for instance, “we have noticed a pattern of emerging quinolone- E. coli resistance,” Dr. Owens reports. “Physicians often think that they need to treat urosepsis with a fluoroquinolone, but 20% of our E. coli this year are resistant to quinolones. Three years ago, it was 1%.”
Why it works
It usually takes only a couple of interventions before physicians become “very attuned and adept at deescalating when cultures come back or switching to oral therapy more quickly,” says Dr. Owens. He says he tends to work with hospitalists less than with other specialties.
At the same time, he adds that the advent of hospitalists makes stewardship programs even more necessary.
“Medical and surgical teams change shifts and services, so there can be a disconnect in care,” Dr. Owens points out. Patients with high acuity are another reason that issues related to antibiotics “slip to the bottom of the list. While we think we can bridge the gap on sign-offs, we often don’t.”
To build a successful program, Dr. Owens says that hospitals need a dedicated clinical pharmacist on the ground. Hospitals also need to compensate a physician to co-administer a program.
“If stewardship is more or less a volunteer program, nobody has time,” Dr. Owens says. He also notes this major misperception: that only “big hospitals can do this” because infectious disease specialists are in short supply in smaller hospitals. According to Dr. Owens, hospitalists in smaller facilities would be ideal to help direct stewardship programs “as long as they’re given dedicated time to do so.
Moving on to UTIs
While physicians may cringe at the notion of being told how to prescribe, Dr. Trowbridge says that members of the hospitalist group appreciate the reassurance that they’re choosing the right antibiotics.
“Antibiotic choice for CAP has gotten much more complicated over the last five years,” he points out. “As long as the clinical decision support can keep up with changes in the literature, clinicians will likely embrace it.”
Next up is designing a similar tool for prescribing for urinary tract infections (UTIs), the center’s No. 1 diagnosis. According to Dr. Owens, a study that the stewardship program conducted with the Maine Medical emergency department looked at the antibiotics patients with UTIs were taking when they came into the ED and what they were prescribed by emergency physicians.
“There was a great deal of variability in the treatment of uncomplicated cystitis in women under age 40,” he says, “signaling a ripe opportunity for intervention.”
Phyllis Maguire is Executive Editor of Today’s Hospitalist