Infectious Disease Experts Urge Implementation of Antimicrobial Stewardship Programs

By Paulina Pineda

The topic of antimicrobial stewardship is gaining momentum, both in and outside the healthcare field. Experts are looking at antimicrobial stewardship programs in hospitals and other care facilities as the next step in combatting the development of multidrug-resistant infections.

Antimicrobial use began in the 1930s and 1940s with the development of penicillin to treat streptococcus, strep throat and gonorrhea. The development of antimicrobials has had a positive effect on the healthcare field, helping reduce infectious mortality and morbidity. It also has helped with advances in surgery and oncology. But as infection preventionists and healthcare epidemiologists are well aware of, the widespread use of antimicrobials has led to the development of antimicrobial resistance.

The Centers for Disease Control and Prevention (CDC) estimates that at least 2 million Americans will develop an antibiotic-resistant infection this year and that 23,000 of those patients will die. The CDC also estimates that antibiotic resistance costs more than $20 billion in healthcare costs and about $35 billion in lost productivity due to hospitalizations and sick days.

But both the Infectious Diseases Society of America (IDSA) and the Society for Healthcare Epidemiology of America (SHEA) have seen the cost and care benefits of antimicrobial stewardship programs, and are calling for AS programs to be required as a condition for hospitals in the Medicare program.

As defined by IDSA, antimicrobial stewardship refers to the “coordinated interventions designed to improve and measure the appropriate use of antimicrobials by promoting the selection of the optimal antimicrobial drug regimen, dose, duration of therapy, and route of administration.”

Antimicrobial stewardship programs can lead to a decrease in antibiotic use and improved patient outcomes, both helping to reduce hospital expenses.

A New York hospital spokesman testifying at the 54th Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC) meeting says that its AS program saved the hospital more than $600,000 a year and helped reduce antibiotic resistant infections in its patients.

John Lynch, MD, MPH, the antimicrobial stewardship program medical director at Harborview Medical Center in Seattle, says he has seen similar results. Harborview, a teaching hospital at the University of Washington, is part of the university’s medical school, which serves five states: Washington, Wyoming, Alaska, Montana and Idaho. It’s also the county hospital. Lynch says he’s seen the hospital benefit from the antimicrobial stewardship program. He says the hospital now has a more uniform approach to complex infections and has had luck optimizing treatment when inappropriate antibiotic treatments don’t work. The hospital has also narrowed pneumonia empiric treatment, among other things.

Nationally, pharmacy budgets over the last 10 years have continued to increase and in many hospitals it can amount to two-thirds of the hospital budget. Lynch says the hospital’s AS program has helped reduce expenses.

Lynch says staff used to meet with the hospital’s financial team to look at costs on a monthly basis for the first two years the program was in place.
“After showing excellent cost savings that oversight was discontinued,” Lynch says.

Now the hospital’s daily cost per patient has decreased by $.50 to a $1 per patient day per year over the last several years, and antibiotic usage is about 15 percent of the pharmacy budget compared to the usual 30 percent to 40 percent, he says.

The hospital’s antimicrobial stewardship program was created in 2003 by members of the infectious disease community, including Timothy H. Dellit, MD, who also co-authored IDSA and SHEA’s antimicrobial stewardship guidelines.

“When this started there were no guidelines,” Lynch says. “Those guidelines developed afterward.”

Lynch says the program is a partnership between infectious disease physicians and pharmacists at the hospital. Attending physicians are also embedded in the program, he says.

Lynch says antimicrobial stewardship programs are about patient safety and the long-term idea of preventing multidrug resistance from occurring or developing.
“It’s about providing the best care at the best cost,” he adds.

But implementing an antimicrobial stewardship program at a teaching hospital can be difficult compared to a more traditional hospital setting, he says, because the staff is constantly rotating. Lynch says to address this issue, the hospital and university have implemented specific guidelines and education into the curriculum. “We get a lot more benefit out of structured education and structured interventions,” he says. “In addition it helps train that person and teach them there is a uniform approach to certain diseases.”

Guidelines include a diagnostic approach and treatment of multidrug-resistant organisms. The program incorporates national guidelines from IDSA and SHEA.

Lynch says the program is also actively engaged with pharmacy and therapeutic committees, which control antibiotic use at a higher level by choosing which antibiotics to include and which not to include in the hospital’s formulary.

Lynch suggests that hospitals interested in creating an antimicrobial stewardship program partner its infectious-disease programs with infection-control specialists. He says the most important part is establishing a team.

“If you don’t have a team in place, the ability to sustain the program is going to be really tough,” Lynch says. “I’ve seen it fail many times at other hospitals.”
He says an optimal team consists of an infectious disease physician as lead, engaging in peer-to-peer communication, and pharmacists. In healthcare facilities that don’t have ID specialists, a physician interested in infectious diseases or a pharmacist who can monitor and provide data can lead the program.

And both Lynch and Amanda Jezek, vice president of public policy and government relations at IDSA, agree that infection preventionists can help support successful antimicrobial stewardship programs.

“[Infection preventionists are a] crucial part of helping everyone in a healthcare facility use antibiotics effectively,” Jezek says.

Lynch also added that a successful program should be focused on what it can realistically implement. He says it should provide education, engage the pharmacy and therapeutic committees to optimize the hospital formulary, and be creative about the opportunities available to the hospital.

Jezek says antimicrobial stewardship programs are a critical part of IDSA’s broader plan because overuse and misuse of antibiotics are “key drivers of resistance and healthcare costs.”

“AS programs can be very effective in improving patient outcomes,” she says. “Still, many healthcare facilities don’t have antimicrobial stewardship programs. This is an obvious goal.”

In September IDSA launched the U.S. Stakeholder Forum on Antimicrobial Resistance (S-FAR), a forum made up of more than 75 national organizations representing the healthcare profession, advocacy groups and the government.

According to the IDSA, the group’s foundational principles include: the U.S. being a leader in a “multi-pronged” effort to reduce the negative impact of antimicrobial resistance and creating a national plan to address antimicrobial resistance that is informed by regular engagement with non-governmental stakeholders.

“IDSA firmly believes that in order to effectively address the public health crisis of antimicrobial resistance, we must bring together a diverse set of stakeholders to work collaboratively and inform federal policy,” says Barbara E. Murray, MD, FIDSA, president of IDSA, in a press release. “We are encouraged by recent heightened federal interest in antimicrobial resistance, and believe now is a critical time to mobilize strong stakeholder voices to work with government leaders.”

The S-FAR partners convened in October at IDWeek, a joint meeting of SHEA, IDSA and the HIVMA.

Jezek says S-FAR aims to promote the development of new antibiotics and also the implementation of antimicrobial stewardship programs. She says because of federal interest, both in the administration and in Congress, the time to address antimicrobial resistance is now. And the government is obviously listening.

On Sept. 18 the president signed the Combatting Antibiotic-Resistant Bacteria Executive Order, directing federal departments and agencies to implement strategies to prevent and contain antibiotic-resistant infections.

“I think the administration’s actions were in response to a lot of advocacy that IDSA and various partners have done over many years to help raise urgency of this issue,” Jezek says. “I think the launch of S-FAR was one key component of that advocacy.”

The executive order was accompanied by a National Strategy on Combatting Antibiotic-Resistant Bacteria and a report from the President’s Council of Advisors on Science and Technology.

According to a White House press release, the National Strategy outlines five goals to be achieved by 2020: Slow the emergence and prevent the spread of resistant bacteria, strengthen national efforts to identify and report cases of antibiotic resistance, advance the development and use of rapid diagnostic tests, accelerate antibiotic research and development and improve international collaboration.

“We’re incredibly excited,” Jezek says. “We can’t declare victory and go home. There’s certainly a great deal to do.”

Congress followed up the administration’s efforts on Sept. 19 by holding a House Energy and Commerce Subcommittee on Health hearing on antibiotic resistance. At the hearing, government officials from the Food and Drug Administration (FDA), professors and IDSA president Barbara Murray testified before the congressional committee on the importance of the development of new antibiotics and strategies to curb antibiotic resistance.

Jezek says the congressional hearing could help further bipartisan efforts to pass the Antibiotic Development to Advance Patient Treatment Act of 2013 (ADAPT) later this year. The ADAPT Act, sponsored by Rep. Phil Gingrey (R-Ga.), would decrease certain pharmaceutical regulations to increase antibiotic research and development.

The act would allow pharmaceutical companies to utilize clinical trials on smaller populations to study new antibiotics for life-threatening infections.

“We’re really encouraged by the events of last week,” she says. “We recognize that there’s still a lot of work to be done, but we have the federal government’s attention.”