Research Suggests Hospital Antimicrobial Stewardship Programs are Beneficial

Antimicrobial stewardship programs implemented by hospitals to combat antibiotic overuse are paying off, suggests new research. Hospitals have seen a decline in antibiotic resistance and costs, according to several studies being presented at the 49th annual meeting of the Infectious Diseases Society of America (IDSA).

Many hospitals implemented antimicrobial stewardship programs even before IDSA and the Society for Healthcare Epidemiology of America (SHEA) released antimicrobial stewardship guidelines for acute care hospitals in 2007.

We believe strongly that antimicrobial stewardship is beneficial and prevents the escalation of resistance in bacterial infections, but its nearly impossible to prove a direct cause and effect, says Ruth Lynfield, MD, chair of IDSAs Antimicrobial Resistance Work Group. These research studies including the longest study to date found a decrease in resistance, as well as a decrease in cost with implementation of these programs. Resistant infections can be very difficult and costly to treat. Unnecessary antibiotic use can cause adverse effects as well as add costs. We hope that studies such as these will help convince other hospitals to invest in antimicrobial stewardship."

However, another study notes there is room for improvement, finding only about one-third of U.S. hospitals are fully compliant with the 2007 guidelines.

Long-Running Program Shows Improvement in Antibiotic Susceptibility

Susceptibility to antibiotics have improved substantially under the antimicrobial stewardship program established in 1993 at Wesley Medical Center, Wichita, Kan., suggesting the program has helped in combating antibiotic resistance. The 17-year study also determined that the money spent on antibiotics decreased during that time period.

The most dramatic improvement is the increase in susceptibility of gram-negative bacteria to standard antibiotic therapy, which coincides with the decrease in use of those drugs as specified by the stewardship program. In 2003, 66 percent of Pseudomonas aeruginosa cultures were susceptible to gentamicin and 68 percent to ceftazidime, but their susceptibility increased by 2009 to 92 and 90 percent, respectively. Susceptibility to ampicillin-sulfate by Escherichia coli increased from 63 percent in 1995 to 83 percent in 2007 and by Klebsiella pneumoniae from 75 percent in 1994 to 97 percent in 2007.

While antibiotics comprised 22 percent of the yearly pharmacy budget at the start of the program, the drugs now make up 9 to 14 percent of the budget each year.

Although the findings dont prove that resistance was reduced due to the program, the reduction in usage followed by the increase in antibiotic susceptibility suggests the program likely had an impact, researchers note.

Weve definitely seen improvements, some gradual, some quite dramatic, says Derick Gross, PharmD, clinical pharmacist in adult medicine at Wesley. Antibiotic resistance of gram negative bacteria is unusually low here, perhaps for several reasons, including the patient population, the location and, were confident, the long-running antibiotic stewardship program.

Antimicrobial Stewardship Programs Save Money

Although antibiotic stewardship programs are not inexpensive to implement, a University of Minnesota study suggests the cost is justified. The university reports antibiotic purchasing cost savings of $732,758 within two years of establishing an antibiotic stewardship program at two of its hospitals in 2007. Net savings to the hospital was $243,758 for those two years after factoring in salary costs for the infectious diseases physicians and pharmacists working on the program. The hospitals saved money by reducing inappropriate antibiotic use, as well as using less-expensive antibiotics when they were warranted.

The average number of antibiotics prescribed per adult patient declined from 2.39 to 2.34 (2.1 percent) and per pediatric patient from 2.98 to 2.37 (20.5 percent). Antibiotic doses per patient/day declined by 7 percent and antibiotic costs per patient/day declined by $7.40. The quality of care was not adversely affected, authors note.

The patients actually benefit because we are treating infections optimally by not using antibiotics when they are not necessary and using less expensive antibiotics that do the job better and more safely than expensive ones, says Susan Kline, MD, medical director for the University of Minnesota Medical Centers Infection Control Program, Minneapolis. We also have seen some trends that suggest the program has prevented emergence of antibiotic resistant bacteria.

Only One-Third of Programs Fully Compliant With Guidelines

U.S. hospitals are taking antimicrobial stewardship seriously, but less than a third are fully compliant with the core and supplemental strategies recommended in the IDSA/SHEA Antimicrobial Stewardship guidelines, suggests a University of Houston-Cardinal Health survey, the first to measure compliance.

Of the 270 U.S. hospitals who completed the survey, all had implemented some components of stewardship, but 184 (68.1 percent) did not meet the definition of fully guideline-compliant. The most common reason for partial compliance cited by 121 hospitals (44.8 percent) was lack of funding and personnel dedicated to the program.

Momentum to implement antimicrobial stewardship programs to improve antibiotic use in hospitals has grown in recent years, which is great news for patients, says Kristi Kuper, PharmD, clinical director of infectious disease at Cardinal Health Pharmacy Solutions, Houston. It was good to learn that all of the hospitals had implemented some components of stewardship, but there is always room for improvement.

Stewardship programs typically are multidisciplinary, involving infectious diseases physicians, pharmacists and other healthcare workers. The programs enact guidelines about the appropriate selection, dosing, delivery method and duration of antibiotics.

They also involve implementation of a variety of tools and components, such as flagging of antibiotic orders that dont follow protocol or currently recommended infectious diseases treatment guidelines. For instance, some doctors automatically prescribe broad-spectrum antibiotics, which are more likely to create resistance if not de-escalated or stepped down to treat the specific infection. In other cases, antibiotics arent necessary at all, because the infection is caused by a virus, which cant be cured by an antibiotic. And sometimes, less-powerful and less-expensive pill versions of antibiotics are recommended, rather than the intravenous form of the drug.

The goal of these programs is to improve patient care by optimizing outcomes and minimizing unintended consequences, such as drug toxicity and antibiotic resistance, says Lynfield, state epidemiologist and medical director, Minnesota Department of Health. The cost research should help convince hospitals of the savings and other significant benefits of fully developed stewardship programs.

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