Lessons Learned from an Ineffective Antimicrobial Stewardship Program
Implementing a successful antimicrobial stewardship program requires planning, top level administrative support, adequate funding, appropriate staffing, ongoing education of staff and prompt reporting of key metrics. Programs that lack any of these elements quickly run into difficulties that can be quite costly in the short and long-term. How do you know whether your program is effective? What happens when a hospital has an ineffective antimicrobial stewardship program (ASP)?
To determine the effectiveness of the ASP at your hospital, you need to monitor the metrics for both processes and outcomes. On the process side, hospitals typically track information such as:
- The percentage of patients treated with antimicrobials who have the reason for the prescription noted in their records
- The proportion of prescriptions that meet hospital-defined guidelines for therapy for agent, dose and duration
- The acceptance rate for recommended changes from inappropriate prescriptions to preferred medications
- Adherence rates for policies such as automatic stops for empiric therapy, IV to oral conversion, discontinuation of duplicative medications and de-escalations
On the outcomes side, hospitals often monitor:
- Patient outcomes: Studies show that mortality rates, length of stay and complications from infections can be reduced by ASPs.
- Patient safety: Clinicians may monitor adverse drug toxicities and development of Clostridium difficile infections, for example.
- Evidence of reduced resistance: Beyond the benefit to the individual patient, antimicrobial stewardship programs also aim to extend the life of available antimicrobials and reduce the development of resistant organisms. Consequently, tracking the rates of multidrug resistant organisms by unit and facility provides a significant measure of an program’s effectiveness.
- Reduced costs: Antimicrobial stewardship programs generally lead to reduced use of antimicrobials, particularly more expensive broad-spectrum antimicrobials. They also often limit the duration of antimicrobial use and diminish the number of treatment failures caused by antimicrobials known to be ineffective for particular infections, which reduces both antimicrobial costs and other expenses associated with longer hospital stays. 1
Ineffective (or absent) ASPs not only fail to achieve the benefits of good stewardship, they also put the hospital at risk for fines and may damage the facility’s reputation. Medicare and private insurers have implemented penalties that continually increase the next few years for poor rates of healthcare-associated infections, readmissions, and other quality measures.
Hospitals that don’t measure up are already seeing reduced reimbursement rates. Further, with infection rates reported through the National Healthcare Safety Network now publically available, hospitals that compare poorly risk losing patients who may choose to use a “safer” facility—or be directed to one by their health plan.
To help you program avoid these problems, make sure you have the key elements recommended by the Centers for Disease Control and Prevention and the Infectious Diseases Society of America in place:2,3
- Leadership Commitment: Dedicate the necessary human, financial and IT resources to the program.
- Accountability: Appoint a single leader, ideally an infectious disease physician, responsible for program outcomes, and establish time and compensation for the role.
- Drug Expertise: Appoint a single pharmacist leader responsible for working to improve antibiotic use, and allocate time and budget for these responsibilities.
- Prioritized Action: Sequentially implement recommended actions, such as systemic evaluation of ongoing treatment need after a set period of initial treatment or implement prospective audits of antimicrobial prescriptions.
- Tracking: Monitor antibiotic prescribing and resistance patterns.
- Reporting: Regularly report information on antibiotic use and resistance to relevant staff and management.
- Education: Educate clinicians, staff and patients about resistance and optimal prescribing.
1. McGowan JE. Antimicrobial Stewardship—the State of the Art in 2011 Focus on Outcome and Methods. Infection Control. 2012; 33:331-337.
2. CDC. Core Elements of Hospital Antibiotic Stewardship Program. Atlanta, GA: US Department of Health and Human Services, CDC; 2014.
3. Dellit, et al. Clinical Infectious Diseases 2007; 44:159–77.