Katherine K. Perez, PharmD, is the infectious diseases and antimicrobial stewardship clinical specialist at Houston Methodist Hospital System. In that capacity, Perez develops, coordinates, and directs antimicrobial stewardship efforts at Houston Methodist’s 8 campuses. Perez is board certified in pharmacotherapy by the Board of Pharmaceutical Specialties with added qualifications in infectious diseases. She spoke recently with Infection Control Todayabout the challenges of launching and maintaining effective antibiotic stewardship programs (ASPs).
Infection Control Today:Just what do antibiotic stewardship programs (ASPs) look like on the ground? Who’s in charge and what part do infection preventionists play?
Perez: I wish I could say there was a one-size-fits-all approach to a successful inpatient ASP, but dedicated resources vary significantly. For the most part, longstanding (15 years+) ASPs with dedicated resources were initially supported by significant cost reductions from decreasing antibiotic use and, over time, their ASP practices became institutional culture even as the drug cost savings went away. Most of the evidence in support of ASPs comes from these types of hospital environments that are in the minority compared to the national healthcare landscape. Although implementing “low-hanging fruit” interventions like switching [intravenous] to oral antibiotics had notable cost benefits for the pharmacy departments in the past, nowadays, it is very difficult to justify dedicated resources based on pharmacy costs alone.
While I am optimistic that the regulatory changes and the increased attention to antibiotic resistance will lead to better defined best practices in different settings, building the business case to do more than meet the bare minimum may not be very attractive to everyone.
From my perspective and experience, medical staff representation at the top (as the medical director or co-director with pharmacy) of the ASP is absolutely critical. Prescribing antibiotics is a medical staff function and responsibility and therefore needs medical staff input at the onset. Once the leadership is defined, setting up a venue to review, discuss, and showcase efforts is necessary to keep the team accountable. I have found that a lot of newer programs tend to overlook this critical step and can spend years making up for it.
Multiple stakeholders are needed at the table to make an ASP successful on the ground—and making a whole lot of people care about something that isn’t causing a problem “today” is difficult. I do think that the lack of tangible metrics to influence immediately can put the ASP in a silo, far away from the infection preventionists who have very specific criteria and direction. If the goals are not aligned from the get-go, it is extremely difficult to get infection control (IC) to be an active member and vice versa. Some examples include working on initiatives to find “ASP optimization” opportunities when cases of [Clostridiodes difficileinfection] are reviewed or discussing culture results with the microbiology lab and pharmacy in tandem.I feel strongly that ASP should be separate and a standalone program to meet the program’s true intention.
I have heard some hospital administrators ask if the ASP is something that can be combined with an infection control program, and while there is obvious overlap, monitoring antibiotic use and performing prospective audit and feedback requires different objectives that don’t always align logistically. It is important to understand that ASP is different than infection control programs—and if resources are spread between the 2—if ASP is added to IC responsibilities or vice versa—there will only be a diluted effect. The synergy is captured when you have both groups at the table with overarching goals in alignment but separate objectives, agendas, and plans to showcase their progress.
ICT: With some prodding by the Joint Commission, the number of antibiotic stewardship programs have grown greatly between 2013 and 2017. But small hospitals seem to have trouble fielding a team. What about stewardship via remote interfacing? Is that possible or does stewardship depend on people being on site?
Perez: Our hospital system has 8 hospitals and has faced many of the same resourcing issues; we have taken a system approach to incorporate overarching restriction policies and stewardship procedures. That alone checks many of the Joint Commission boxes. With that said, I do think it is very important to have someone on the ground who is truly responsible for ASP. For some of our hospitals, it has been the pharmacy managers who wear many different “hats”—but will take time to sit down and review the reports that come from “system” and really discuss local ASP issues 1 on 1 with me. We make a plan, set a few deliverables, and schedule the next meeting. We have been very successful with this approach and it constantly keeps the activity going. What is great is that it doesn’t have to be any 1 huge intervention; it can literally be a provider level discussion, but it establishes and maintains the program’s local ownership and visibility.
ICT: What changes do you see coming for antibiotic stewardship programs in 2020?
Perez: One of the most significant barriers to an ASP’s success is access to data. The ability to benchmark and trend drug utilization based on users, units, indications, infections, etc. is very difficult to do on a local level and makes standardizing on any large scale a herculean effort. The [National Healthcare Safety Network, Antimicrobial Use] module serves as a great starting point, but I really think that this is the 1 aspect of ASP that is “easy” to outsource if needed and would certainly lift a significant portion of the manpower burden. Multiple clinical decision support tools exist to do this and I know I certainly rely on 1. If these tools could be more widely and broadly adopted it would be 1 avenue to help standardize and define a large public health threat.