Health care institution starts antimicrobial program
Pharmacists help direct prescribing habits
Hospital-acquired infections with methicillin-resistant S. aureus (MRSA) have increased tremendously in recent years, with one study finding that MRSA-related hospitalizations in the United States more than doubled between 1999 and 2005.1
Hospitalizations related to all S. aureus infections increased by 62% during this same period.1
Another disturbing trend is the increase in emergency department visits for skin and soft-tissue infections, which one study found to have increased significantly from 1993 to 2005.2
Medical experts have attributed the increase to the emergence of community-associated MRSA.2
There also are increasing problems with drug-resistant gram-negative infections, including increasing antimicrobial resistance among intensive care unit pathogens in the United States.3
And there is a trend of super infection, such as Clostridium difficile colitis, in which bacteria overgrow in the colon of patients who've received antibiotics, producing a toxin and severe diarrhea.4
These and the other increases in antibiotic-resistant infections have led health care organizations to focus on prescribing habits through quality assurance programs. But one organization has taken such efforts a step further than most with the development of the Infectious Diseases Management Program.
"This is a group of infectious diseases physicians, both pediatric and adult, and infectious diseases-trained pharmacists," says B. Joseph Guglielmo, PharmD, a professor and chair of the department of clinical pharmacy at the University of California-San Francisco (UCSF) in San Francisco, CA.
"The group is concerned about outbreaks, surgical control, and the group interacts constantly and regularly throughout the year," Guglielmo says.
What makes the group novel is its inclusion of an infectious diseases (ID) pharmacist.
Although the Infections Diseases Society of America recommended in January, 2007, that organizations create antimicrobial stewardship teams that include pharmacists, few organizations have embraced this model, Guglielmo says.
"All that said, we've been doing this for a while," he adds.
The group's goals are to improve antibiotic prescribing habits, improve cost effectiveness of antibiotic therapy, and reduce the inappropriate use of antibiotics that has led to a resistance crisis, he says.
"In 2005, I spoke in front of our medical center's executive medical board and presented data," Guglielmo says. "I showed how there has been an incredible increase in resistant bacteria in the institution and how there is a lack of an antibiotic pipeline specific to gram-negative infections, such as pseudomonas."
The board agreed that something drastic needed to be done, and so they dropped the traditional policy of leaving antibiotic prescribing to patients' attending physicians and said that ID pharmacists and physicians would have the final word on antibiotic prescriptions, he says.
"If there's a disagreement, then the ID physician has the final word," Guglielmo says.
"Our primary emphasis is in the intensive care unit setting," he explains.
Antibiotics now are prescribed according to guidelines that the medical center has agreed upon.
Guglielmo has been studying the impact of following these guidelines and the impact of changes to how antibiotics are prescribed. The study is expected to show a massive reduction in inappropriate antibiotic use since the changes were implemented, he says.
The study might not be able to show whether there has been a simultaneous impact on antibiotic resistance, he notes.
"That's difficult to show because there are so many reasons one sees an increase or decrease in resistance," Guglielmo says. "It depends on the kinds of patients, what kind of antibacterial things are done — such as whether people washed their hands."
Also, any short-term trend might be caused by having one period of time in which patients were much sicker than they were in another period of time, Guglielmo says.
However, antibiotic use is a risk factor for resistance, and if the study shows that inappropriate prescribing habits are reduced, then that would be a positive indicator for reducing antibiotic resistance.
"I have come to the conclusion that I don't need to prove that reducing inappropriate antibiotic use will make a difference because showing that you've reduced inappropriate antibiotic use is a surrogate marker," Guglielmo says.
The program works this way: An infectious diseases pharmacist carries a beeper and is responsible for approving the use of restricted antibiotics, he explains.
"It's less important what you start with," Guglielmo notes.
The key is to obtain the necessary medical information that will inform a decision of whether to discontinue the antibiotics or to use the most narrow spectrum antibiotics possible, he says.
Once lab results are available, a narrow spectrum antibiotic that is recommended for those particular results can be prescribed. Even when the results are inclusive, the team will make a change, Guglielmo says.
"If you don't have a reasonable indication for the antibiotic, then we have the authority to get rid of it," he says. "We do it tactfully."
For instance, a patient who has been placed on a broad-spectrum antibiotic might have a culture that does not indicate infection by a particular organism, Guglielmo says.
"We argue that you back off of the broad-spectrum antibiotic to something much narrower," he explains. "The primary physician might say, 'I'm uncomfortable with narrowing the coverage or discontinuing the drug.'"
The primary physician's decision could be based on a chest X-ray that shows fluid in the lungs. But if the lab results do not support the diagnosis of a bacterial infection, then it's also possible that the patient is experiencing heart failure or acute respiratory distress syndrome, Guglielmo says.
In cases where a patient's prescribed antibiotics are not what is recommended in the organization's guidelines then the ID physician, pharmacist, and primary team, which could be a surgical or transplant team, will work it out.
"We look on a daily basis at all of the patients who are on antibiotics in the ICU," Guglielmo says.
One key to changing a medical center's mindset over antibiotic use is to remind physicians that patients who become infected with antibiotic resistant bacteria are experiencing an adverse drug effect, Guglielmo says.
"I've always argued that infection with resistant bacteria should be considered an adverse drug event," he adds.
The ID team's goal is to individualize antibiotic therapy to each patient, following the guidelines that if there is no medical evidence supporting the "big gun" of broad-spectrum antibiotics, then they should be discontinued.
"If we don't see any evidence that it requires a broad-spectrum drug, then we go a few notches less," Guglielmo says.
References
- Klein E, Smith KL, Laxminarayan R. Hospitalizations and deaths caused by methicillin-resistant Staphylococcus aureus, United States, 1999-2005. Emerg Infect Dis 2007;13:1840-1846.
- Pallin DJ, Egan DJ, Pelletier AJ, et al. Increased U.S. emergency department visits for skin and soft tissue infections, and changes in antibiotic choices, during the emergence of community-associated methicillin-resistant Staphylococcus aureus. Ann Emerg Med 2008;51:291-298.
- Eagye KJ, Nicolau DP, Lockhart SR, et al. A pharmacodynamic analysis of resistance trends in pathogens from patients with infection in intensive care units in the United States between 1993 and 2004. Ann Clin Microbiol Antiomicrob 2007;6:11.
- Nelson R. Antibiotic treatment for Clostridium difficile-associated diarrhea in adults. Cochrane Database Syst Rev 2007;18:CD004610.
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content