Infectious Diseases faculty lead new hospital antibiotic stewardship initiatives

Tuesday, May 21, 2013

Prescription MedicineThis month, Infectious Diseases faculty members are implementing a new approach to the way Duke University Hospital uses and monitors antibiotics.

Under the direction of Deverick Anderson, MD, MPH, associate professor of medicine (Infectious Diseases) and Rebekah Moehring, MD, MPH, medical instructor (Infectious Diseases), Duke’s antibiotic stewardship program is launching a new, data-driven program in May that will optimize antibiotic use in the hospital and directly affect and improve patient care and safety.

In the last 10 years, attention to the wise uses of antibiotics in hospital care has grown nationally because of increasing rates of drug resistance and lack of new antibiotics to treat drug-resistant organisms, Moehring said.

In 2007, the Infectious Diseases Society of America published guidelines for antibiotic stewardship. Since then, most institutions have developed programs that help clinicians optimize their antibiotic use.

Taking a new approach

“For the past decade at Duke, we have had a passive approach to stewardship,” Anderson said. That approach included education materials, best practices, and a website – Duke Custom ID – intended to guide prescribers at Duke. “But this program has relied on physicians to look at the information and apply it. What we are doing now is expanding the program to have a more active role in the hospital.”

The new initiatives will be led by the Antimicrobial Stewardship and Evaluation Team (ASET), consisting of pharmacists and a group of physicians from the Division of Infectious Diseases.

The new approach involves active interventions, such as reviews by a pharmacist of the use of specific antibiotics to ensure that the prescribed drug is working as intended. There also will be mandatory consultations with Infectious Diseases physicians for patients with Staphylococcus aureus bacteremia.

The team is also exploring rolling out rapid molecular diagnostic tests that would help physicians prescribe appropriate therapies for their patients sooner, and the team would like to create a flag in Maestro Care, the hospital’s new electronic patient record system, that would indicate if a patient is on the wrong antibiotic or not on antibiotics when they have an infection, a safety precaution the team calls bug-drug mismatch.

Health care reforms suggest that stewardship will be an important metric for the quality of care provided by hospitals, Anderson said.

“We will have to demonstrate that we have the ability to deal with stewardship,” he said.

Improving patient care

There will be numerous benefits to patients, including more monitoring by pharmacists and specialists for certain antibiotics.

Moehring and Anderson say that decreasing unnecessary antibiotic use will decrease the rate of hospital-acquired C. difficile – a painful infection when good bacteria in the gut are depleted from strong antibiotics.

“The major risk factor for acquiring C. difficile in the hospital is antibiotic use, and so we’re optimistic that these interventions, while they will have direct patient benefit, may have more hospital benefit as well by decreasing C. difficile in the hospital,” Anderson said.

In addition, the Duke team will be analyzing antibiotic utilization data, something they have not been able to do in the past because the data was not available in the systems used prior to Maestro Care.

“We are hoping to provide benchmarked data reports for different groups in the hospital, ICU-specific reports, physician-specific reports, service lines, which will provide ways to compare progress over time. Then we’ll be able to identify good comparators within the hospital and outside the hospital to gauge where our biggest use of antibiotics may be and in which areas of the hospital –  which providers, which types of patients – as a way to identify subsequent interventions,” Anderson said.

In order to track this data, the team will start with a list of patients that meet the criteria for intervention, then they will track which patients they saw and whether the recommendations were followed. The team will look at the number and amount of drugs used, the length of the patient’s hospitalization and how often they got C. difficile.

In addition to the direct patient benefits of the program, the antibiotic stewardship group also expects the program to result in some cost savings for the hospital and to provide some educational benefits for patients and physicians.

“Hopefully as we are discussing patients with providers, we will increase awareness of decision-making for antibiotic use and improve the level of knowledge and comfort for using these drugs appropriately,” Moehring said.

Anyone who is interested in learning more about the program can contact Anderson and Moehring or look out for the ASET team in the hospital.

“The interventions that we’re starting now are what we consider phase one. We think there’s lots more for us to do,” Anderson said. “We’d like to work on proving the value of our team and our program before we start tackling some of the more difficult questions.”

The ASET team is part of an overall effort by the Department of Medicine to focus on programs that provide high value patient care that takes a patient-centered approach that can result in higher quality care and cost savings.

“This program is important because it focuses on the best treatment choice for each patient by applying the best knowledge and tools to each situation,” said Bimal Shah, MD, MBA, assistant professor of medicine (Cardiology) and director of Quality Improvement and Credentialing for the Department. “In the long run, we want what is best for patients, and when we make choices based on that, patients, providers and the hospital benefit.”