Stewardship Program Examples

 

Antimicrobial stewardship programs are effectively and successfully being implemented across the nation, helping to ensure the highest quality healthcare for patients. Please e-mail us any success you’d like to share.

Here are just a few of the success stories.

Implementing a Cost-Effective Antibiotic Stewardship Program at Two Non-Teaching Community Hospitals

Faheem Younus, MD, Chief of Infectious Diseases
Jennifer Bui, Pharm. D, Critical Care, Clinical Manager
Angela Kaitis,  RPh, BSP, PharmD, CMTM, Administrative Director, Pharmacy Services – UM-UCMC
Stephen Low, RPh, B.S.Pharm, Administrative Director, Pharmacy Services – UM-HMH

University of Maryland-Upper Chesapeake Medical Center (UM-UCMC)
University of Maryland-Harford Memorial Hospital (UM-HMH)

Upper Chesapeake Health (UCH) comprises two community non-teaching hospitals, 203 (UM-UCMC) and 103 (UM-HMHl) beds each. We are members of the University of Maryland Medical System.   

Hospital leadership has been committed to support our ASP since 2009.  Our administration entrusted one Clinical Pharmacist and an Infectious Disease physician to lead a robust ASP.   Our goal is to promote appropriate use of antimicrobial therapy, minimize the emergence of antimicrobial-resistant bacteria, prevent hospital acquired C. difficile infections, and reduce healthcare cost without adversely impacting the quality of care.

Critical components for our successful ASP:

Our ASP activities:

We recently implemented a maximum 5-day stop for azithromycin and 7-day stop for levofloxacin due to the recent FDA warnings on fluoroquinolones.  We plan to reduce our Level 1 ABX duration from 72 hours to 48 hours to further decrease the inappropriate use of restricted ABX.  We are also looking into communicating our recommendations to the prescribers via texting using Doc Halo.

As a result of our robust ASP, cumulative savings of ABX purchases of approximately $1,000,000 was calculated over a 4-year period.

Our percentage of ABX purchases over total pharmacy purchases decreased from 15% to 9%, and our cost per patient day decreased from $16 to $8.  

ASPs can be successfully implemented in resource-limited, non-teaching community hospitals resulting in significant cost savings. Leadership support is critical to the success of our ASP.

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Antimicrobial Stewardship – Focus on De-escalation

Kevin J. Chapple, Pharm.D., BCPS
Clinical Pharmacy Manager
Shore Health System
University of Maryland Medical System
Easton, MD

Shore Health System is a 2-hospital health system with a total of 196 licensed inpatient beds on Eastern Shore of Maryland.  It is a member of the University of Maryland Medical System.  In 2008, the Antimicrobial Stewardship Committee (ASC) was formed consisting of our infectious disease physician, an intensivist, an infection control nurse, a microbiologist, a hospitalist, and four clinical pharmacists.

The focus of the committee was clear from the start – to increase the quality of infectious disease care at Shore Health while reducing antimicrobial costs.  In addition, a long term goal is to stabilize and eventually improve resistance patterns within the System.  Beginning in 2009, the ASC developed and implemented an antimicrobial de-escalation protocol for the clinical pharmacists to use.  This protocol was approved by the Pharmacy and Therapeutics Committee.

The protocol consisted of a form that is placed in the progress notes section of the medical record suggesting to discontinue one or more antimicrobials for a more appropriate one, or to discontinue the antimicrobials altogether if clinically warranted.  The ASC meets quarterly, and a report of these recommendations was prepared for Committee review and quality assurance purposes.

There were no cases of clinical harm with any patients who received an ASC recommendation.  In 2010, there were a total of 97 recommendations by the clinical pharmacists, and all but 4 of these were accepted.  Upon analysis of the use of our highest cost antimicrobials, we found that our costs decreased by 13.7% over the previous year when adjusting for admission rates.  In addition, our defined daily doses (DDD) were reduced by 9.1%. While these cost savings and improved utilization cannot be attributed to the de-escalation initiative alone, it represents a new culture of thought at our institution.  The presence of an Antimicrobial Stewardship Program has facilitated a higher level of awareness about microbial resistance and proper antimicrobial selection.

It is too soon to tell whether this program has affected our antibiogram, but it is something we are paying close attention to.  For Shore Health System, 97 recommendations in one year is just the beginning.  With a larger focus on antimicrobial stewardship, our de-escalation program will continue to grow by focusing on an increasing number of targets.

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Implementing Antibiotic Stewardship Through Clinical (non-ID) Pharmacists Without Availability of ID Physicians

Jim Nicholson, PharmD
Clinical Manager
Cardinal Pharmacy Management
Methodist Medical Center of Oak Ridge
Oak Ridge, TN

We are 300 bed community hospital.  We have 4 decentralized clinical staff pharmacists that are participating in stewardship activities.

Description of Program
The stewardship program began in late 2005. In 2006, the decentralized pharmacists began rounding with the hospitalists group. Currently their day to day activities include:

Day to day activities

• Daily antimicrobial culture review – Between 0700 and 0830, reports are generated from Laboratory Information System by Microbiology and sent via pneumatic tube to the inpatient pharmacy. The reports include final verified results, organism ID, sensitivity and source.  They are sorted by location and the pharmacist picks them up when they head up to their patient care areas.  Using these reports, the pharmacists work with the physicians to streamline therapy.
• Target drug list – This is generated in a report developed by IT and is then imported into a software program called “Report to Web”. Each pharmacist has their log in and they go in and get the various reports that are pre-programmed to generate. Usually these are run around 0830am. Approximately 90% of the drugs included on this report are antibiotics. The pharmacist matches up culture data with the antibiotics, evaluates renal function to determine if meds need to be dose adjusted, and reviews to determine if patient is eligible for IV to PO conversion.
• Renal dosing – reviews all patients for appropriate meropenem and quinolones dosing based on renal function. We have a P&T approved protocol that allows the pharmacists to automatically do this and write an order that does not require physician co-signature.
• Pharmacokinetics- similar to most hospitals, we have a pharmacokinetic dosing program.  Pharmacy is consulted for vancomycin and aminoglycoside dosing almost 100% of the time. 
• Pharmacodynamics – we have an autosubstitution program which is approved by P&T and allows pharmacists to convert orders for piperacillin/tazobactam and meropenem to regimens that optimize pharmacodynamics and are evidenced based.

Other activities

The Infection Control Committee oversees the stewardship program and the P&T approves any programs related to formulary substitution or dosing of antimicrobials. We also have approved empiric therapy and surgical prophylaxis guidelines that are based on current literature and our annual antibiogram. 

We conduct about 3 medication use evaluations per year related to antibiotics. We identify the MUEs that we are going to perform based on high use or high cost drugs. The final MUE report includes summaries of individual patient data as well as information on susceptibilities (from the antibiogram) as well as a summary of  aggregate use of the drug that is expressed using Defined Daily Dose per 1000 patient days. These results are shared with the P&T Committee, Infection Control, Hospitalists (at their meetings) and Intensivists (with the head of dept 1:1). 

We have a closed antibiotic formulary and several automatic therapeutic substitutions in place.

Measures

We monitor pharmacy expenditures on antibiotic and also monitor antibiotic use in defined daily doses.

Lessons Learned

Factors that have contributed to our success

• Having an engaged, well respected ID physician who was comfortable with contemporary antibiotic related issues such as pharmacokinetic/pharmacodynamics was helpful. His interaction with other medical staff as well as participation on key committees was very helpful to Pharmacy.
• A strong P&T Committee that positively responded to evidence based medicine.
• A strong relationship between Microbiology personnel and Pharmacy. Also, having a very responsive lead Micro tech who knew how to run reports and made sure that the culture and susceptibility reports were sent to Pharmacy on a daily basis was very helpful
• Allowing the pharmacists to run their own target drug lists on demand and having reports easily accessible.
• Engaging decentralized clinical staff pharmacists to do some of the basic stewardship activities allowed Pharmacy to have a larger coverage area than if the program solely relied on 1 person such as the clinical manager to do the program.
• Sharing results routinely with Hospital Administration.
• Since most hospitals have limited ID resources, physicians that cover large patient groups can be allies in a stewardship program. At our hospital, this group was the hospitalists. They covered 65% of our admissions.
• Direct communication between pharmacists and prescribers allowed for more dynamic conversations. Notes left on the chart only allow communication of that 1 thought at 1 time and are not dynamic.  

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Antimicrobial Stewardship Activities for Wesley Healthcare Wichita, KS

Stephanie Kuhn, PharmD, BCPS
Infectious Disease Pharmacist
Kyra Hagan, PharmD
Pharmacy Practice Resident
Wesley Healthcare
Wichita, KS

Wesley Healthcare is a tertiary-care, community teaching facility and Level 1 trauma center licensed for 760 beds and 102 bassinets. The Antimicrobial Stewardship Program is run by the antimicrobial management program medical director and infectious disease pharmacist along with participation from physicians, pharmacists, microbiology personnel, nursing personnel, and senior administration.

The goal of the program is to encourage the appropriate use of antimicrobials by selecting the appropriate agent, dose, duration, and route of administration in order to achieve optimal patient outcomes, while minimizing toxicity and the emergence of antimicrobial resistance.

Pocket Resource

The Antimicrobial Stewardship Program compiles an Antibiotic Essentials guide which contains information for prescribers and pharmacists. Key information includes an antibiogram derived from the hospital’s microbiological data, empiric antibiotic selection and dosing for common infections, dosing guidelines for vancomycin and aminoglycosides, and information for proper renal adjustment of antibiotics.

Pharmacy-Driven Stewardship Procedures

Policies and procedures are developed and approved by the Pharmacy and Therapeutics Committee allowing implementation of certain common institution-approved procedures in order to expedite changes. Some of the pharmacy-driven procedures are as follows:

• Automatic conversion of certain antibiotics from IV to PO if the patient is able to tolerate meals and oral medications without use of anti-nausea medication
• Renal adjustment of antibiotic doses at order verification and throughout the patients’ stay as warranted
• Automatic consults for pharmacokinetic dosing on vancomycin and aminoglycosides for adult inpatients
• Initiation or discontinuation of oseltamivir, dependent on respiratory influenza PCR results
• Ordering of labs necessary for monitoring such as serum creatinine, liver function tests, and creatinine kinase

Future Projects

Further development of pharmacy-driven procedures include expansion of the pharmacokinetic dosing service to the pediatric population and protocols designed to reduce time to action following results from rapid diagnostic tests.

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Antimicrobial Stewardship Activities for the Jackson Memorial Hospital/ University of Miami.

Lilian Abbo, MD
Medical Director of Antimicrobial Stewardship Program
Assistant Professor of Clinical Infectious Diseases
Jackson Memorial Hospital
University of Miami, Miller School of Medicine
Miami, Florida

Jackson Memorial Hospital is a 1500-bed tertiary care teaching hospital serving the Miami-Dade County. We provide care to a large group of patients including victims of trauma, oncology and one of the largest solid organ transplant centers in the country. Our antimicrobial stewardship program is staffed by an infectious diseases physician (0.8 FTE) and 2 infectious diseases clinical pharmacists (1 full-time infectious diseases pharmacy resident). The program was implemented 8 years ago and rebranded in 2008 with increased visibility and research oriented goals to improved patient safety and quality of care. It is funded by the hospital.

Our major goals are:

• Ensuring optimal selection, dosing and duration of antimicrobials.
• Limit the development of antimicrobial resistance
• Improve hospital wide education regarding antimicrobial use and resistance
• Conduct research to measure the impact of antibiotic stewardship interventions on patient safety and quality of care

Over the past years, we’ve developed activities that have been quite successful. Some of them have been:

• In collaboration with the Centers for Disease Control and Prevention (CDC) Division of Healthcare Quality Promotion we surveyed over 500 faculty and housestaff physicians to asses knowledge, attitudes and perceptions towards antimicrobial use and resistance. Based on the differences and similarities between both groups we are implementing targeted interventions to improve the use of antimicrobials.
• Development of “GotaBug” our intranet antimicrobial stewardship website and recently also an intitution restricted GotaBug iPhone application. It provides access to all the affiliated hospitals’ antibiograms, antimicrobial renal dose adjustments, IV to PO conversion of antimicrobials, antibiotic and ethanol locks as well as educational guidelines in the management of infections.
• Antimicrobial pre-authorization program. Based on toxicity, broad spectrum and cost the following antimicrobials require authorization by the antimicrobial stewardship program: carbapenems (except in the intensive care units were empiric use is not restricted), tigecycline, polymixin B, linezolid, daptomycin, aminoglycosides, amphotericin, aztreonam, quinopristin/dalfopristin, telavancin, ceftazidime, micafungin, voriconazole and posaconazole. Key components of this program include audit and feedback from our stewardship team for continued therapy of all restricted antimicrobials.
• Development of hospital specific surgical prophylaxis guidelines. We have modified the antimicrobial order forms to limit the duration of surgical prophylaxis beyond 24 hours. A process has been implemented in collaboration with the department of anesthesiology to ensure appropriate selection of antimicrobials, timing and redosing of peri-operative antimicrobials.
• Extended infusion of carbapenems and piperacillin/tazobactam. Based on PK/PD analysis, we have implemented this intervention to improve patient outcomes and cost-effective use of these antimicrobials.

  We measure utilization by DDD and benchmark our utilization of restricted and non restricted antimicrobials.

  In addition, we provide series of educational lectures to incoming housestaff every year as well as through the year in various departments. In the lectures we usually distribute promotional pens with our slogan “Let’s STOP antimicrobial resistance” and the intranet website link.

  We also continuously provide institution-specific antimicrobial pocket cards that highlight:

  • Key info on our stewardship program (pre-authorization antimicrobials, pager numbers, pharmacy numbers)
  • Detailed table with renal dose adjustment of antimicrobials
  • Detailed dosing protocols for weight-based vancomycin therapy and for aminoglycosides
  • Bacterial and fungal algorithms with recommended empiric selection of antimicrobials based on hospital formulary and local patterns of resistance
  • Antibiograms pocket cards printed bi-annually
  • Intravenous to oral transition of antimicrobials
  • Information regarding our intranet website for additional resources

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Starting an Antibiotic Stewardship Program at Smaller Hospitals:

Gary R Kravitz, MD
St. Paul Infectious Disease Associates, Ltd.
St. Paul, MN

In addition to providing antibiotic stewardship at four metropolitan hospitals (110 to 400 beds), our 6-person ID Group has initiated a plan to conduct antibiotic stewardship programs at four smaller non-metropolitan hospitals. These “small-town” hospitals have only 40-75 beds, lack infectious disease specialists on-site, and are located at a distance from our base of operations. All sites are owned or managed by the Allina Healthcare System and share a common EMR. We have sought to take advantage of this common EMR platform to overcome the barriers of distance and size.  So far the program has been fully implemented in only one location and is progressing at two other sites.

Here is how we have done it:

Groundwork: You can’t begin a stewardship program at a hospital where you are unknown. To create an ID presence at each hospital we start by having a member of our ID practice chair the Infection Control Program. Next we give a series of lectures to the medical staff on the key topics in infection control/antibiotic stewardship (i.e: MRSA, C difficile infection, treatment of urinary tract infections, and antibiotic-resistance). Lastly, we provide 24-hour availability for “telephone” infectious disease consults to the staff physicians of these hospitals. These services combine to create the credibility needed to commence an antibiotic stewardship program. It takes time and effort to reach this point.

Stewardship via remote access:  We use the common EMR to make “virtual” antibiotic stewardship rounds on from our base hospital in St. Paul while simultaneously speaking on the telephone with the clinical pharmacist at the remote site hospital. Rounds are conducted twice weekly. The Allina health system has developed a custom program that culls the inpatient charts on all patients on antibiotics and displays key clinical data like vital signs, laboratory studies, and microbiology reports.  Using this program and the insights of the on-site clinical pharmacist, we are able to expeditiously identify cases of excessive or inadequate antibiotic therapy. After completing the review with the pharmacist, we leave an electronic note addressed to the physician in the “communications” section of the chart in those cases where we feel that antibiotic therapy could be enhanced or eliminated. We include our cell phone number should the physician wish to call us. The local pharmacist compiles a record of the number of recommendations made and the percentage of recommendations accepted.

So far the clinical pharmacists have been enthusiastically receptive to our program.  Their ID training at baseline was surprisingly good and showed further improvement as they gained “on the job” experience.

We have contracted with each of the participating hospitals to receive hourly compensation for our efforts.  We keep a log of the time spent on each component of the program (infection control, telephone consults, lectures and stewardship) on a master spreadsheet that we submit for payment monthly.

I firmly believe that with the appropriate groundwork, remote access EMR, engaged clinical pharmacists, and a receptive medical staff, that antibiotic stewardship can be done effectively in any acute-care or long-term care hospital.  Indeed, we often hear hospitalists conveying our stewardship message to other clinical staff.

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Improvement Efforts in Antibiotic Therapy for the Christian Hospital

Bhumi Pathak, Pharm.D.
Clinical Pharmacist
Christian Hospital
BJC Healthcare
St. Louis, MO

We are an 485 bed non-teaching hospital.  We do not have an ID pharmacist on staff.  Our stewardship program is run primarily by clinical pharmacists with support from pathology and a consulting ID physician.”

We began our stewardship efforts by examining how antibiotics were being prescribed at our hospital.  We found that a lot of our use was directed at infections caused by MRSA, Pseudomonas and Enterococcus.  Thus, we felt that efforts to improve the appropriate selection of empiric antibiotic therapy and de-escalating therapy based on culture results for these pathogens would result in decreased antimicrobial resistance and substantial cost savings. 

To accomplish our goals we:

• Ensured the appropriate empiric antibiotic selection was made for at risk patients, by collaborating with pathology to create an antibiogram specifically for MRSA, Pseudomonas, and Enterococcus in the ICU units, and consulting with the ID physician to establish empiric therapy guidelines. In addition, the clinical pharmacists conducted risk factor assessments on all patients initiated on any anti-MRSA, anti-pseudomonal, and anti-enterococcal antibiotics within 24 hours of therapy start date. 
• Required cultures to be drawn prior to initiating any IV antibiotic therapy. This was done with collaboration between Pharmacy and the Emergency Department to create a system to notify nursing of the need for cultures prior to initiating antibiotic. 
• Ensured appropriate de-escalation of antibiotic therapy based on culture results. The clinical pharmacist documented whether appropriate de-escalation occurred and intervened on cases where needed.

We believe that careful monitoring of our outcomes is critical and so we measured an outcome for each of our interventions. Our efforts have been very successful to date. At the end of the pilot period:

• 80% of patients got appropriate empiric antibiotics
• 92% of patients got baseline cultures prior to antibiotic start
• 56% of our recommendations to de-escalate therapy were accepted
• 64% of patients had therapy modified based on culture results

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Stewardship Activities for the NYU Langone Medical Center

Sapna Mehta, MD
Medical Director of Antimicrobial Stewardship Program
NYU Langone Medical Center
New York, NY

NYU Langone Medical Center is a 970-bed tertiary care teaching hospital serving the metropolitan New York City area. Our antimicrobial stewardship program is staffed by an infectious diseases physician (part-time) and two infectious diseases clinical pharmacists (full-time). The program is funded by the hospital, and has three major goals:

• Ensuring antimicrobials are optimized – the right drug with the narrowest spectrum for the appropriate duration of therapy;
• Reduce C. difficile illness and carbapenem-resistant Enterobacteriaceae ;
• Conduct research to measure the impact of antibiotic stewardship on patient safety.

Over the past year, we’ve initiated new stewardship activities that have been quite successful.

• We implemented a tiered system of antimicrobial pre-authorization and ordering which enables providers to order timely initial broad-spectrum therapy (in the setting of high rates of MDROs) yet incorporates guidance and review by our antimicrobial stewardship team. This system places all antimicrobials into 3 tiers:
  • Tier 1 antimicrobials are most restricted and require pre-approval.  The initial course of therapy lasts only 4 days, after which the clinician is required to contact the program and review microbiology and clinical results to decide on type and duration of therapy.  Antimicrobials in this group include carbapenems, most fluoroquinolones, tigecycline, polymixin B, linezolid and daptomycin.
  • Tier 2 antimicrobials may be ordered by all providers for 4 days only – then the clinician must call the program to review the patient data and decide on type and duration of therapy.  Antimicrobials in this class include 3rd and 4th generation cephalosporins, piperacillin-tazobactam, and aztreonam.
  • Tier 3 antimicrobials are unrestricted. 

Key components of this program include early audit and feedback from our stewardship team for continued therapy of all restricted antimicrobials, 4-day automatic-stop on initial orders, electronic reminders to clinicians if an antimicrobial is about to expire and all clinicians, including infectious disease physicians, are included in the review process . In addition to ensuring appropriate use of antimicrobials, a major goal of the program is to reduce C. difficile illness and carbapenem-resistant Enterobacteriaceae by targeting the use of fluoroquinolones and carbapenems, plus ensuring appropriate duration of therapy for all antimicrobials.

We measure utilization both by DDD and days of therapy. Prior to implementation of the program, our baseline monthly utilization (in DDD) for oral ciprofloxacin ranged from 24.6 to 34.3 (per 1000 patient days) and for meropenem 10.1 to 13.3 (per 1000 patient days). Six months after implementation, we have seen a reduction in utilization for these targeted agents with oral ciprofloxacin use ranging from 18.3 to 21.4 and meropenem use 4.4 to 6.1 in the last 2 months.

• In addition, we developed an institution-specific antibiotic info pocket card with 3 main features:
  • Key info on our stewardship program (pre-authorization procedures, pager numbers, pharmacy numbers)
  • Detailed dosing protocols for weight-based vancomycin therapy and for aminoglycosides
  • A table of formulary antimicrobials with helpful info (e.g. loading dose, dosing for different syndromes, medication interactions/contraindications) and renal adjustment doses

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ResistanceMap is a collection of tools summarizing national and subnational data on antimicrobial use and resistance in North America and Europe.