Keys for Success, Getting Started
Keys for Success
A Physician “Champion”
The engagement and support of a key physician can be critical in gaining buy-in from other prescribers. This physician should be well-respected at the facility and committed to efforts to improve antibiotic use. However, the champion need not have training in infectious diseases.
- Physician Champion
Ed Septimus, MD, FACP, FIDSA, FSHEA
HCA, Nashville, TN
Support from the leadership team at the facility is essential in improving the buy-in of clinical staff to stewardship interventions and programs. Ideally, such support includes funding for the stewardship efforts, but it should also include visible commitment from key facility administrators.
Tailoring Interventions to Local Problems
Local issues should be assessed to develop targets for antibiotic stewardship interventions. For example, facilities with high rates of C. difficile infection should focus interventions on those most likely to impact C. difficile. Addressing local problems will further increase buy-in for the interventions.
Measurement of an Outcome
It is critical that those leading a stewardship intervention pick one or more process or outcome measures to follow the success of the intervention. The selection of outcome measures that are important to key groups can be very helpful, but these will need to tailored. For example, antibiotic costs might be an important measure for administrators, but are not compelling for clinicians. Reductions in C. difficile infections or adverse events are likely to be more important for clinical audiences. While resistance is an important endpoint and a topic of interest for clinicians, most experts in antibiotic stewardship agree that it is not an ideal, primary endpoint as resistance rates change very slowly and can be influenced by a variety of factors, in addition to antibiotic use. That said, all facilities should follow levels of antibiotic resistance through the production of a regular antibiogram.
These are relatively simple, but important interventions that can be implemented in any setting and with limited resources.
Review Blood Cultures that Grow Organisms
The primary mission of antibiotic stewardship is to improve patient safety. Ensuring that serious infections are treated properly is an important step in that direction. A review of positive blood cultures can be an important place to start. Blood stream infections are serious and associated with high morbidity and mortality if they are not treated properly. It is also an infection where the diagnosis is relatively straightforward. Moreover, with some important exceptions, like coagulase negative Staphylococci, most positive blood cultures do represent real infections. A review to ensure that all hospitalized patients with positive blood cultures are on antibiotics to which the bacteria is susceptible can be an important patient safety improvement. This review could be done by pharmacists, nursing, infection control or others, with physician back-up for cases that might require more review. Also, this type of review sets the stage for subsequent interventions that could be targeted at reducing unnecessary treatment of contaminants as well as narrowing therapy and optimizing the duration of therapy.
Review of Key “Never” Combinations
There are some antibiotics which almost never need to be used in combination as they have overly duplicative spectra of activity. One of the best examples is the use of two agents to cover anaerobic pathogens. In most instances, using these combinations only increases toxicity. Hospitals can use pharmacy data systems to create alerts for these combinations which could then be reviewed to see if the both agents are truly needed.
Align the Formulary with Local Susceptibility Data
It is important to ensure that you have the right antibiotics on your formulary and these decisions should be driven by local susceptibility data. Creating an antibiotic formulary can not only help direct clinicians to the right group of antibiotics, but it can create opportunities for cost savings by increasing the efficiency of pharmacy supply.