What Every Health Care Executive Should Know: The Cost of Antibiotic Resistance

Chapter 5: Antibiotic Stewardship

Stephen G. Weber, MD, MS
Assistant Professor Section of Infectious Diseases Medical Director of Infection Control and Clinical Quality University of Chicago Medical Center and JCR Consultant Infection Prevention and Control Services
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Is antibiotic misuse promoting the spread of MDROs and increasing costs at your hospital?
Dr. Anderson admitted an elderly nursing home patient to your hospital with pneumonia. He ordered blood cultures and an antibiotic (moxifloxacin), which the patient began three hours after admission. In spite of the antibiotic, the patients condition worsened. The microbiology reports were returned the next day and showed that the blood cultures were growing Pseudomonas aeruginosa resistant to moxifloxacin but susceptible to imipenem.

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Is antibiotic misuse promoting the spread of MDROs and increasing costs at your hospital?
Dr. Anderson changed the antibiotic to imipenem as soon as the test results became available. The patient was transferred to the intensive care unit (ICU) where she worsened and required mechanical ventilation. She spent two weeks in the ICU before being transferred to the internal medicine service.
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Is antibiotic misuse promoting the spread of MDROs and increasing costs at your hospital?
The patient was finally transferred back to her nursing home after a 24-day hospital stay. The total cost of her admission was more than $100,000. Dr. Anderson later learned that nearly all of the patients admitted from that particular nursing home with infection ended up requiring treatment with broad-spectrum antibiotics because of a high frequency of multidrug-resistant organisms (MDROs). Are you sure that antibiotics are used judiciously at your hospital?

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Objectives
To describe the role of antibiotic abuse and misuse in the spread of MDROs in hospitals To describe the structure and functions of an effective antibiotic stewardship program.
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To provide an introduction to the costs and potential savings associated with an effective stewardship program

Antibiotic Misuse, Abuse and MDROs

The use of antibiotics, even when well-intentioned and clinically appropriate, promotes the selection of MDROs
Exposure to antibiotics, which kill susceptible bacteria, permits the survival of strains with the genetic capacity to evade or elude the effect of the antibiotics

Broad-spectrum antibiotics, which are most commonly prescribed in the hospital, are especially associated with the selection of MDRO In the hospital setting, it has been estimated that up to one-half of antibiotic use is unnecessary
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Do You Know What Youre Spending to Treat Resistant Organisms?

550 Hospital IV Expenditures ($ millions) 500 450 400 350 300 250 200 150 100 50 0 2004 2005 2006 2007

Carbapenems Anti-MRSA Drugs* Glycylcyclin es Penicillins Fluoroquinolones

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Expenditures for drug classes used to treat resistant organisms greatly increased from 2004 to 2007 In contrast, expenditures for older drug classes (eg, penicillins, fluoroquinolones) decreased over the same period

Antibiotic Stewardship Program (ASP) Overview

Antibiotic stewardship is a multisystem team approach that involves limiting inappropriate use of antibiotic agents while optimizing the selection, dose, duration and route of therapy with the most appropriate drug for the patients condition ASPs have been associated with 22-36% reductions in antibiotic use and are associated with numerous clinical benefits

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Structure of an Effective ASP

Broad-based membership
Infectious Diseases clinician and pharmacist, medical staff members, microbiologist, pharmacists, information systems expert, infection preventionist and/or healthcare epidemiologist

Regular meetings
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Policy and performance improvement initiatives Plans for disseminating new interventions to frontline clinicians

Integrated into Medical Staff Organization

Report through Pharmacy and Therapeutics Committee

Functions of an Effective ASP

Review of Pharmacy Data
Information about antibiotic utilization can be used to document and analyze trends within the hospital and to benchmark against external or historical standards Precise and established methods exist for documenting and reporting antibiotic utilization data. Defined daily doses can be determined for any antimicrobial agent and adjusted for hospital size and census Trends in drug acquisition and seasonal variation in usage must be accounted for in any rigorous analysis of antibiotic utilization

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Antibiotic Utilization Example

78.0 DDD/1,000 patient days

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Cefazolin is administered 1 g every 8 hours. Defined daily dose (DDD) = 3 431 days of cefazolin administered during quarter 1 (1,292 DDD) 200 bed hospital @ 90% capacity = 16,560 patient days

Functions of an Effective ASP

Review of Clinical Microbiology Data
Antibiotic utilization data documents one cause of MDRO spread in hospitals. The effect of misuse and abuse is best measured through examining trends in the frequency of MDRO Most hospitals generate a summary of antibiotic susceptibility patterns (Antibiogram) at least annually The antibiogram is an essential tool for setting antibiotic policy and for decision-making at the bedside Susceptibility data must be collected and reported in a rigorous fashion and should serve as the basis for performance improvement initiatives.
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Functions of an Effective ASP

Integrating Data and Implementing Change
Analysis of utilization and susceptibility data may prompt both recommendations for antibiotic stewardship and infection control Changes should be approached cautiously and with sensitivity to the expectations of the clinical staff Consider promoting efforts related to clinical quality and patient safety, rather than exclusively on cost savings
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Education and Guidelines

Guidelines promoting rational and appropriate antibiotic use should be widely disseminated Consider a focus on duration of antibiotic therapy

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Functions of an Effective ASP

Formulary Decisions and Antibiotic Restriction
An important, albeit unpopular stewardship tool Limits clinicians in terms of antibiotic prescribing privileges May be associated with unintended epidemiologic consequences

Review and Feedback of Antibiotic Use

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May be done in aggregate or for individual clinicians Target problem prescribers

Computerized Order Entry

Nearly limitless stewardship opportunities

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Costs and Savings of ASP

Savings in the range of 20-35% have been reported
Mostly realized through reduced acquisition costs Indirect savings may also be achieved

ASP costs mostly driven by salaries and support for ASP leaders and participants
Consider 0.5 FTE for a physician and 1.5 FTE for pharmacists

Hospital pharmacy budget may provide information about potential cost savings
Antibiotic drugs should make up no more than 18% of the total pharmacy budget

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Overview of Tools
Antibiogram Template Proactive Strategies for ASPs Antibiotic Audit Form Competency Questions CEO Talking Points

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Antibiogram Template
Get the information where its needed in the hands of clinicians who prescribe antibiotics
The template provides a standardized summary of which antibiotics are most effective at your organization

Brief information about stewardship isolation precautions included

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The template can be customized for nearly any population depending on the needs and desires of clinicians
Available as both a tri-fold pocket resource and for distribution electronically

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Sample Tool

Antibiogram Template

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Proactive Strategies for ASPs

This document summarizes the strategies for implementing an ASP using guidelines from the Infectious Diseases Society of America (IDSA) and the Society for Healthcare Epidemiology of America (SHEA) Prioritizes core versus supporting strategies using IDSA-US Public Health Services rating scale
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Proactive Strategies for ASPs

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Antibiotic Audit Form

In the hands of a sophisticated reviewer, this tool forms the basis of building a comprehensive overview of the appropriateness of antibiotic use Use aggregate data to inform stewardship policy, as the basis for educational and improvement initiatives or to quantify the impact of such programs Use individual data to identify problem prescribers
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Sample Tool

Antibiotic Audit Form

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Competency Questions
It is difficult for prescribers to keep up with the latest new drug agents and trends in antimicrobial resistance
Knowledge can really be power when it comes to MDRO prevention!

ASP Competency Questions can be readily adapted to any teaching format or forum currently employed for prescribers at your hospital ASP Competency Questions offer the opportunity to tailor the message and really help our colleagues understand that MDRO control IS their job.
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Sample Tool

Competency Questions

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CEO Talking Points

Even those who will never write a prescription have a stake in rational and appropriate antibiotic use

These talking point stress the universal interest we share in rational prescribing
Your doctors and other prescribers need to know that irrespective of his or her clinical background, your senior executive really understands the risk

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Sample Tool

CEO Talking Points

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For More Information:

Visit Our Website: http://www.jcrinc.com/MDRO-Toolkit/ Contact: JCRs Consulting Services Group 630-268-7400 ConsultingServices@jcrinc.com

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What Every Health Care Executive Should Know: The Cost of Antibiotic Resistance
Joint Commission Resources (JCR), supported in part by funding from Ortho McNeil, Division of Ortho-McNeil-Janssen Pharmaceuticals, Inc., is privileged to announce the release of What Every Health Care Executive Should Know: The Cost of Antibiotic Resistance, an innovative, evidence-based, and practical collection of senior leadership resources. This manual is presented to your institution as an informational tool only. JCR is solely responsible for the development and contents of this tool. You are solely responsible for any decision to use the manual as a guideline for assisting your institutions in establishing safe infection control practices. Obviously, it is only a guideline and you would have to make the decision as to whether it needs to be tailored to fit the practices and settings at your individual institution. JCRs production of this manual for Ortho-McNeil, Inc. is on a non-exclusive basis, and is not an endorsement of that company or its products, or a statement that its expertise or products are superior to those of other comparable companies. JCR will make available all the subject matter contained in the Infection Prevention and Control Toolkit and Workshops to any other party interested in furthering JCRs efforts to help improve quality and safety.

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