Published in the October 2012 issue of Today’s Hospitalist
What do hospitals need for effective antibiotic stewardship?
According to a speaker at this year’s Society of Hospital Medicine’s annual meeting in San Diego, they don’t really need a formal, independent stewardship program headed up by infectious disease specialists and pharmacists. Instead, hospitals need hospitalists to step up and recognize that antibiotic stewardship falls squarely into their domain of patient safety and quality improvement.
“If you are in a facility with the resources to have a stewardship program, that’s a fantastic adjunct. But most don’t,” Arjun Srinivasan, MD, told hospitalists at a session on antimicrobial stewardship. “Ultimately, we have to shift from this notion that stewardship is something done by a management team to a model where we all recognize that it is something we have to fold into daily care.”
Without such a paradigm shift, Dr. Srinivasan said, the massive patient care and public health problems associated with the poor use of antibiotics will only continue, starting with the very real, well-documented rise in morbidity and mortality associated with resistance. Dr. Srinivasan is associate director for health care associated infection prevention programs at the Centers for Disease Control and Prevention (CDC) in Atlanta.
“For some patients in hospitals today, we are already in a post-antibiotic era,” Dr. Srinivasan said. “We have no effective therapy for them, and we are not going to get new ones any time soon.”
The good news, Dr. Srinivasan told hospitalists, is evidence shows that improving prescribing practices can at least partially reverse some resistance problems. That’s true both for the overall population and individual patients.
Take C. difficile infection. The rising rate of both morbidity and mortality associated with the infection “is one of the most compelling reasons that we need to improve our use of antibiotics in hospitals,” he noted.
Previous exposure to antibiotics “particularly fluoroquinolones, the most commonly prescribed class of antibiotics in hospitals “is the single biggest risk factor for developing C. difficile, increasing the risk of getting the infection three-fold for 60days. To make matters worse,the epidemic strain of C. difficile (NAP-1) is resistant to fluoroquinolones “so it has even more of a selection advantage when patients are prescribed a fluoroquinolone to treat some other infection.
When one hospital completely banned fluoroquinolones in one ICU, doctors found that the use of all antibiotics in that unit dropped 30% “an indication that physicians weren’t replacing the off-limits fluoroquinolones with other drugs. The hospital also saw its C. diff infection rates fall, Dr. Srinivasan said. Results were published in the March 2009 issue of Infection Control and Hospital Epidemiology.
Such studies make “a compelling case that we can put the horse back in the barn,” Dr. Srinivasan said. “The problems of resistance aren’t inevitable or irreversible.”
Hospitalists should start with the two most common diagnoses for which inpatient antibiotics are prescribed: community-acquired pneumonia (CAP) and urinary tract infections (UTIs). Data suggest, Dr. Srinivasan said, that there is “lots of room for improvement.”
- Improve diagnosis and documentation. “A lot of patients get labeled as having CAP who don’t,” said Dr. Srinivasan.Before joining the CDC, he worked at Baltimore’s Johns Hopkins University Hospital and was the founding director of its antibiotic management program. When infectious diseases experts at Johns Hopkins looked at CAP management, they found that of 106 patients started on the CAP protocol in the hospital’s emergency department, more than one-quarter were dropped from the protocol on the floor because they didn’t have pneumonia. (According to Dr. Srinivasan, external adjudicators upheld that decision.)
“Obviously, the antibiotics in those instances could be stopped,” he said. But that points to another big problem in many hospitals, he says: inadequate documentation. Clinicians may not be sure why patients have been started on antibiotics in the first place, and many are reluctant to stop a course midstream.
“It might have been started for something serious,” said Dr. Srinivasan. “If you know why a patient is on an antibiotic, you can have a level of confidence to say, ‘We started it for pneumonia. I’m sure they don’t have pneumonia. I am comfortable stopping it.’ “
- Use culture results to change therapy. The Johns Hopkins team also learned that another quarter of patients started on antibiotics in the ED could have been switched to a narrower drug, based on their microbiologic data. Researchers found, however, that only three of the 16 patients in that category were switched.”One challenge with CAP is that we don’t have great diagnostics, and we are left treating it empirically because we don’t have culture results,” Dr. Srinivasan said. “But this finding was really interesting because not only did the physicians have culture results, but those results would have allowed a change in therapy.”
- Reduce duration of therapy. If doctors knew and followed evidence-based guidelines, they’d treat most patients with CAP for five days. Instead, he said, the Johns Hopkins researchers found that the total median antibiotic duration for CAP patients was 11 days. According to a meta-analysis published in the September 2007 issue of the American Journal of Medicine, patients with mild to moderate CAP can “safely and effectively” be treated for seven days or less. The recommendation to treat for only five days was part of Infectious Diseases Society of America guidelines on treating CAP that were published in a March 1, 2007, in a Clinical Infectious Diseases supplement.For many patients, that problem is made worse at discharge. “I hear lots of examples where they start the clock over,” said Dr. Srinivasan. Pneumonia patients receive five days of therapy in the hospital, “then they get sent home on a 10-day course, almost as if the inpatient antibiotics hadn’t been given at all.”
Urinary tract infections
As for UTIs, Dr. Srinivasan said they are often overdiagnosed and treated with less-than-optimal drugs for too long.
“One pitfall is that often, patients have bacteria in their urine but they don’t have a UTI,” he noted. “Bacterial cultures of urine are often sent for the wrong reasons.”
Hospitals that have successfully cut back on antibiotic use for UTIs have helped doctors and nurses break the habit of sending routine urine cultures. The goal is to end the antibiotic treatment of asymptomatic bacteriuria.
Education on the proper use of urinary catheters is also key. Studies continue to show that anywhere from 30% to 50% of urinary catheters are unnecessary and that their use greatly increases UTI risk.
Another problem in many hospitals is that UTIs are treated with drugs that do not work. At Johns Hopkins, for example, “Cipro had become the reflex treatment,” said Dr. Srinivasan.
“But when they looked at the susceptibility profile for E. coli isolates “which are the no. 1 cause of UTIs “ciprofloxacin had become less effective for treating E. coli.” While that might not be the case in all institutions, “you won’t know unless you work with your microbiology lab to get the data and find out what will work best.”
“Hospitalists have the greatest influence over how antibiotics are used in hospitals,” Dr. Srinivasan said. “We cannot drug-discover our way out of this problem.”
Deborah Gesensway is a freelance writer who covers U.S. health care from Toronto.
A push toward improved prescribing
ONE WAY TO TACKLE ANTIBIOTIC MISUSE is to link hospital accreditation, licensing or payment to related quality measures. To that end, the Centers for Disease Control and Prevention (CDC) is working with the Centers for Medicare and Medicaid Services (CMS) to test a few measures.
According to Arjun Srinivasan, MD, the CDC’s associate director for health care associated infection prevention programs, CMS auditors will pilot-test several questions when they do this year’s survey of hospitals that participate with Medicare and Medicaid. Hospitals will not be cited for failing these measures because the agencies are just at the testing stage.
“Facilities need to be pushed” to improve antibiotic prescribing, Dr. Srinivasan told hospitalists at this spring’s Society of Hospital Medicine annual meeting. The challenge, he added, is finding the right tool to do so. (A pilot version of CMS’s new infection control worksheet is online.)
Here are the five measures being tested:
1. A hospital has a multidisciplinary process in place to review antibiotic utilization, local susceptibility patterns and antimicrobial agents in the formulary, plus has evidence that those processes are being followed.
2. A hospital has systems to prompt clinicians to use appropriate antimicrobial agents.
3. Antibiotic orders include an indication for use.
4. A hospital has a mechanism to prompt clinicians to review antibiotic courses after 72 hours of treatment.
5. A facility has a system to identify patients receiving IV antibiotics who could be switched to oral therapy.