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Building an antimicrobial stewardship program: Simple steps for better antibiotic management can save money and reduce the IC burden

Infection control

Simple steps for better antibiotic management can save money and reduce the IC burden

After reading this article, you will be able to:

  • List ways an antimicrobial stewardship program can help lower your hospital’s infection rate
  • Illustrate low-cost methods of implementing a program

Preventing the spread of multidrug-resistant organisms (MDRO) in your facility is increasingly important. With close attention from The Joint Commission through the National Patient Safety Goals and an increased cost association with these organisms, infection prevention efforts have never been more vital.

But infection prevention may not be the only way to reduce MDRO infections in your facility. Although hand washing will always remain the most effective way to halt the spread of diseases, you may find that appropriate use of antibiotics can provide additional support in lowering your infection rate.

Judicious and regulated use of antibiotics can reduce infections, save your facility money, and provide much more control over infections, says Richard H. Drew, PharmD, MS, BCPS, professor at Campbell University College of Pharmacy and Health Sciences and associate professor of medicine (infectious diseases) at Duke University School of Medicine in Durham, NC.

“To use [antibiotics] optimally relative to dose, and relative to selection and duration, obviously is all already part of that equation,” Drew says. “There is no question whatever we are doing wrong now we are going to pay for and we are already paying for.”

Starting the program

Allison V. Tauman, PharmD, MPH, implementation manager at VHA Performance Services in Irving, TX, helped establish an antimicrobial stewardship program at Hospital of Saint Raphael in New Haven, CT. Tauman published the results in the May Hospital Pharmacy, and recommends organizing a collaborative group dedicated to antimicrobial stewardship. She suggests setting goals to reduce antibiotic usage, which means establishing baseline data and measuring progress as the program develops.

“To quantify the problem, it’s important to know where you start and where you go, and how much progress you have made, so I think the first step would be to measure your utilization or your utilization patterns in the hospital, usually based on defined daily doses per 1,000 patient days,” Tauman says.

Drew says it also helps to evaluate the resources available to your hospital. Although larger hospitals typically have the expertise and funding for a more extensive program, even smaller community hospitals can initiate stewardship measures.

“There are ways that hospitals can do stewardship in an expertise-limited environment, can still do the basics of stewardship,” Drew says. “So in those particular settings, we do things like IV to oral programs and dose optimization. Sometimes you can run preapproval programs where you establish appropriate criteria for use. And certainly things like surveillance and feedback on antibiotic prescribing habits; that can be done largely without necessary dedicated resources and not necessarily focused expertise.”

Switching from IV to oral, and dose optimization

One simple measure facilities can take is establishing a system within the pharmacy department that allows a switch from IV to oral ingestion of antibiotics.

Prescribing antibiotics intravenously exposes the patient to potential bloodstream infections. If the drug can have the same effect when taken orally, the risk of infection decreases, and the patient often spends less time in the hospital. Drew suggests working with the pharmacy to establish a list of drugs that have good bioavailability and equal effectiveness and then establishing a checklist of requirements for when a patient could take those drugs orally.

“As you generate a profile of an agent that has high oral bioavailability, you can adequately define safe use in a stable patient who is swallowing, the need for perennial antibiotics,” Drew says. “In many, not all, but many of those cases, you can switch to the oral, save the complications of the IV line, and then potentially discharge patients earlier.”

Switching from IV to oral antibiotics is one of the easier parts of an antimicrobial stewardship program, and it affects areas outside of infection control, says Tauman. The Hospital of Saint Raphael established a preapproval program that automatically switched patients from IV to oral when they met certain criteria.

“[IV to PO] actually plays right into an infection control issue, where if you take the line out of the patient, then they are less susceptible to a bloodstream infection, which is the first concern,” Tauman says. “Number two is the lower cost, increased patient satisfaction, and getting the patient out of the door quicker because they aren’t hooked up to a line, and that might have been the only reason they had an IV in.”

Additionally, implementing dose optimization guidelines into the pharmacy department helps cut down on antibiotic usage, which saves money and potentially protects against more aggressive MDROs in the future.

“I think most pharmacists are comfortable with dose optimization, at least in terms of appropriate dosing relative to organ function and then some of the therapeutic drug monitoring,” Drew says.

Achieving cost savings

An added benefit of this program that will please your hospital administration is the potential cost savings that an antimicrobial stewardship can provide.

More judicious use of antibiotics not only decreases money spent on drugs, it can also reduce infections, patient days, and staff resources, which can indirectly save money. The Hospital of Saint Raphael focused specifically on automatic conversion from IV to oral antimicrobials and appropriate antimicrobial use. According to Tauman’s article in Hospital Pharmacy, the percentage of patients receiving oral fluconazole increased from 63% to 77%, and the percentage of those receiving oral linezolid increased from 54% to 71%. As a result, the hospital saw a 6% decrease in total antibiotic use and a cost savings of approximately $874,000 annually, based on the 60-day trial.

Although antimicrobial stewardship programs often provide cost savings, Drew says that this isn’t always the case, nor should it be the focus of the program.

“Giving someone an expensive antibiotic may result in saving their lives and having to stay for several days to recover, and so you’ve spent a lot of money on antibiotics and hospital resources, but certainly that’s the outcome that you’re going after,” Drew says. “So the goal in the scorecard of costs can certainly be a motivator, but it shouldn’t be the primary driver. So when you start to get more elaborate programs, you do focused programs on education, you do probably more elaborate safety monitoring programs because one of the goals of this program is safe use of antibiotics, not just effective use.”

The safe use of antibiotics is also important for the control of antibiotic-resistant organisms. As more resistant organisms surface, infection preventionists and pharmacists have to keep up with prevention efforts and antibiotics. “The pipeline is not very exciting for new antibiotics, especially in the gram-negative pathogens, so we have these multidrug-resistant gram-negative pathogens, but we cannot see the light of day in terms of new drugs,” Drew says. “There’s really no potent new class of gram-negative drugs coming out.”


Adapted from Briefings on Infection Control, September 2009, HCPro, Inc.