A Little Goes a Long Way: Stemming Antibiotic Resistance by Using Less

By Michael J. Alkire

Prompt initiation of antibiotics to treat infections has been proven to reduce mortality and save countless lives. But evidence has shown that use of these drugs far exceeds what is clinically necessary, leading to patient harm, excess costs and an increase in antibiotic-resistant bacteria worldwide.

According to the CDC, up to half of patients treated in the U.S. receive unnecessary or inappropriate therapy, including multiple antibiotics when either one or neither would be the best approach. More specifically, recent research by Premier and the Centers for Disease Control and Prevention (CDC), found that 78 percent of hospitals had evidence of treatment with potentially unnecessary and duplicative intravenous (IV) antibiotics.

And now we’re paying the price.

The CDC estimates that antibiotic resistance – when an organism that is resistant to antibiotics infects a patient – afflicts more than 2 million people in the U.S., costing $20 billion in excess healthcare costs and 23,000 deaths per year. Our research with the CDC pointed clinicians to three specific unnecessary redundant IV combinations that could have led to an estimated $163 million in excess costs alone.

In September 2014, President Obama issued an executive order to quell this growing public health concern, and in March his National Action Plan for Combating Antibiotic-Resistant Bacteria was released. The action plan goals, which Premier pledged to support, include:
• Antibiotic stewardship programs (ASPs) in all acute care hospitals by 2020
• Benchmarks to reduce antibiotic use by 50 percent in outpatient settings and 20 percent in inpatient settings by 2020

ASPs and the electronic surveillance of antibiotic use and resistance are two of the most proven strategies available to help prevent the inappropriate use of antibiotics.

“Stewardship is critical, because antimicrobial resistance presents such enormous problems in infection control and patient outcomes,” says Jonathan Zenilman, MD, chief, division of infectious diseases at Johns Hopkins Bayview Medical Center and professor of medicine at Johns Hopkins School of Medicine.

In 2011, the CDC’s National Healthcare Safety Network (NHSN), the nation's most widely used healthcare-associated infection tracking system, developed a mechanism for facilities to report and analyze their antibiotic use and resistance data as part of local and regional antibiotic stewardship efforts. These data are the key to unlocking opportunities to do things more safely and efficiently. During the pilot project, we were proud to support the integration of these data with 25 percent of the participants being Premier members. Results from the project helped inform NHSN and providers, and we are taking the learnings to enhance our safety analytics.

Zenilman suggests that the growing emphasis on antimicrobial resistance presents health systems with the opportunity to:
• Develop restricted formularies that address the needs of the population.
• Engage pharmacists, physicians, epidemiologists, and administrators in developing protocols and algorithms for managing antibiotic use.
• Shorten and target antibiotic treatment.
• Identify key stakeholders who are major prescribers of antibiotics – such as hospitalists, surgeons and other providers – and develop curricula and programs to target those prescribers.

North Oaks Health System (Hammond, LA) is an example of how using a data-driven ASP program to identify, target and eliminate the use of antibiotics when it does not result in better outcomes can have a tremendous impact on reducing patient risk for antibiotic-resistant infections. 

While reviewing a performance report in 2011, North Oaks’ clinical pharmacist noticed outlier rates of duplicative use, extended use and overuse of antibiotics within their data. So, North Oaks put an ASP in place by hiring a pharmacist certified in infectious disease to review prescriptions and intervene in the event of duplicative or inappropriate use.

With just that one pharmacist, North Oaks saw a 1,000 percent return on investment in avoided medication expense. They then expanded the program to include another full-time infectious disease physician specialist and a second rounding pharmacist to make bedside antibiotic recommendations. After four years, the team delivered $2.5 million in savings, or $60 reduction per discharge. And even more importantly, the program reduced patient antibiotic resistance in their facility. Effectiveness of antibiotics used to treat pseudomonas (bacteria that can cause infections), for instance, increased from 82 percent to 98 percent.

Collaboration also helps providers target specific quality and safety improvement areas, identify and share best practices, and further accelerate change to avoid preventable harm. Since 2010, the 365 hospitals participating in Premier’s national QUEST collaborative have prevented 21,700 instances of harm, such as HAIs, by driving ASP techniques into patient safety practices, such as for obtaining timely blood cultures and use of appropriate antibiotics to improve sepsis care. Today QUEST members are using the Premier/CDC research to focus on reducing the overuse of the three IV combinations it identified.

Data-driven collaboratives like QUEST coupled with clinical surveillance allow health systems to leverage and share evidence-based practices, pinpoint opportunities, assess progress and share learnings with other providers so they can duplicate the improvement.

We have the tools and knowledge to determine when enough is enough in antibiotic prescription and move away from the “more is more” culture of fee-for-service healthcare. Let’s use them.

Michael J. Alkire is chief operating officer of Premier, Inc.