Guidelines offer tips on improving antimicrobial stewardship program
Start with low-hanging fruit
As each pharmacy director faces the daunting challenge of improving or initiating an antimicrobial stewardship program with limited resources, there are a few strategies that can make this process work more smoothly.
"You need to start with the low-hanging fruit," suggests Richard Drew, PharmD, MS, BCPS, professor of pharmacy at the Campbell University School of Pharmacy in Buies Creek, NC, and an associate professor of medicine in infectious diseases at Duke University School of Medicine in Durham, NC. Drew also is a co-author of antimicrobial stewardship research, including a recently published paper that discusses recent antimicrobial stewardship guidelines.1
"You need to target the things that are well established and don't require a high amount of specific or specialized expertise or extra training," Drew says. "One program is IV oral switch programs."
Many hospitals, including small hospitals, have developed pharmacy-screening programs in which providers can easily see where patients meet criteria to be switched to oral medication, he notes.
"That to me is low-hanging fruit, because a staff pharmacist can do this if the criteria has been established," Drew adds. "It's pretty objective."
As hospital leaders increasingly hear about how antibiotic resistance is a health and safety threat, it is becoming easier for pharmacists to promote an antimicrobial stewardship program.
"Stewardship can save money and optimize outcomes and may help to survey — if not stabilize — resistance problems," Drew says. "Stewardship people look at trends in antibiotic resistance patterns and how we can change routine antibiotic use to improve outcomes or reduce resistance, which is why we're using old drugs differently and are consolidating dosing."
The antimicrobial stewardship guidelines have accelerated this discussion in many hospitals, he adds.
Another example of attainable changes would involve pre-approval and restriction programs, Drew says.
"If you've established appropriate criteria for selected drugs, then pharmacists are pretty integral in implementing these and validating the criteria that's in place for pre-approval use," he explains.
"Pharmacists are not applying specific expertise," Drew says. "They're saying, 'This is what other people say is appropriate.'"
Pre-approval programs are valid entities in settings where the hospital has limited resources and limited training, he adds.
Antimicrobial stewardship guidelines identify the pre-approval audit and feedback as an area that needs direct expertise from a pharmacist.
"There needs to be some level of feedback as to prescribing habits, and the feedback and education were identified as part of the guidelines, as well," Drew says.
"Often pharmacists are not necessarily dedicated to infectious diseases or to antimicrobial stewardship, but they can provide some feedback on prescribing habits and drug utilization habits," Drew notes. "They might say, 'Practitioner A uses 10 times more of a restricted drug than does Practitioner B.'"
All of these are ways to start an antimicrobial stewardship program in a low-resource setting.
If a hospital or health system has a few more resources then there are some additional programs that can be implemented.
For example, there might not have to be as focused attention on saving the hospital money in a stewardship program where the hospital has adequate financial and staffing resources to fund this enterprise.
"Traditionally, the programs have been giving corporate staff a scorecard of how they save money," Drew says. "The guidelines do a good job of saying, 'We need to think much beyond that because optimizing outcomes and the safe use of drugs are as admirable a goal as saving money.'"
Safety first
Safety must come first.
"There are ways that costs can be saved while maintaining or potentially improving outcomes, but that shouldn't be the sole driver," Drew says.
"We have programs here, and we dedicate them to different outcomes," he explains. "We have programs we believe are dedicated to cost savings."
Then there are projects that deal with resource utilization, such as the one that involved writing guidelines on monitoring fungal concentrations.
The hospital had some difficulty with antifungal drug levels, and so a program was started that targeted the utilization of laboratories, Drew says.
Another program looked at dosing algorithms and vancomycin levels. Its purpose was for safety, not cost savings, he adds.
"In more advanced programs the issue is to expand beyond saving a dollar in drug costs," Drew says.
"If the mindset of the hospital is to analyze costs in a silo, then they'll look solely at the drug budget," he says. "The idea is to get out of the silo mentality, and you need people who are trained and experienced with antimicrobial stewardship."
Reference
- Drew RH, White R, MacDougall C, et al. Insights from the Society of Infectious Diseases Pharmacists on antimicrobial stewardship guidelines from the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. Pharmacotherapy 2009;29:593-607.
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