ASHP launches antimicrobialstewardship initiative to head off bacterial Armageddon
Experts say the situation is urgent
Hospital pharmacists are among the front-line warriors, fighting to maintain the antimicrobial arsenal in a battle in which it appears the bacteria are winning.
Antimicrobial resistance is on the rise, including some particularly virulent bugs brought home from the Iraq war. And pharmaceutical company investments in new and more power antimicrobials have plummeted.
The situation is very urgent, says Keith Kaye, MD, MPH, professor of medicine and corporate director of infection prevention and antimicrobial stewardship at Detroit Medical Center and Wayne State University in Detroit, MI.
"With antimicrobial resistance growing and more and more governmental regulations around antibiotic resistance and hospital-acquired infections, we need to get a much stronger grasp on how we're using antibiotics," Kaye says.
Health system providers should educate staff how to use antibiotics in the most effective and optimal way, he adds.
"We've always had antimicrobial resistance, but the pharmaceutical industry has kept up with it by developing new drugs," says Robert P. Rapp, PharmD, FCCP, professor of pharmacy and surgery emeritus at the University of Kentucky Medical Center in Lexington, KY.
"That's come to an absolute screeching halt, especially on the gram-negative side," Rapp says. "We have no new drugs in development for the next 10-15 years, so the bugs have caught up with us."
Drug resistant infections killed more than 65,000 people in the United States last year, according to a recent Associated Press series on antibiotic resistance worldwide.
"The only thing standing between us and doomsday is better antimicrobial stewardship and better infection control," Rapp says.
One harbinger of the doomsday scenario is multidrug-resistant Acinetobacter baumannii infections, which began to rise from obscurity in the United States to an increasing problem seen in hospitals after the start of the Iraq war. Veterans returned home colonized or infected with the gram-negative bacteria that can be found in Iraqi soil. A hearty bug that can survive for weeks in bed linens and on door knobs, A. baumannii infection can spread quickly through a hospital.1-3
"It's becoming a huge problem for hospitals," Rapp says. "Some of these have extreme resistance, and with poor infection control it spreads throughout hospitals."
Young people who have skin and soft-tissue infections with A. baumannii now are being isolated and untreated, as they'll eventually recover. But for frail and elderly hospital patients, the infection can be deadly.
This disturbing trend means that hospitals, clinics, long-term care facilities, and other providers need to engage in much better infection control methods than they have in the past decade and start antimicrobial stewardship programs that include a pharmacist who is trained in infectious diseases.
"For the first time since the antibiotic era began, we haven't caught up by having new drugs, and that poses an enormous risk," Rapp says. "There is some federal funding for antibiotic research at present, but it's not very much, and it needs to be increased tremendously."
The American Society of Health-System Pharmacists (ASHP) launched an antimicrobial stewardship initiative in mid-June 2010, with a web portal that contains stewardship tools, information, webinars, other resources, and links. It's available at www.ashpadvantage.com/stewardship.
"ASHP is getting involved big time because they want to see pharmacists move quicker to develop these programs, and pharmacists need to be leaders here," says Rapp, who is the chair of the expert panel on antimicrobial stewardship for ASHP.
Pharmacists with infectious disease training are a crucial component of any antimicrobial stewardship program, typically pairing with an infectious disease (ID) physician or a medical staff champion, says Steve Cano, RPh, MS, senior director of the pharmacy and chief pharmacy officer at Cambridge Health Alliance in Somerville, MA.
"Other players are involved, but that pairing of pharmacy-physician leadership is crucial," Cano says.
Among ASHP's new material is a free, downloadable white paper called, "A Hospital Pharmacist's Guide to Antimicrobial Stewardship Programs," which lists Kaye, Rapp, and Cano on its expert panel. The 21-page guide includes tables with core strategies, proposed care bundles for antibiotic prescribing, and process measures for use in evaluating antimicrobial stewardship program impact.
The web portal is entirely free and open to the public. It serves as a communication tool that can help pharmacists, physicians, and others establish antimicrobial stewardship programs, says Ron DeChant, MS, BSPharm, director of scientific projects at ASHP Advantage.
The website lists various facts about antimicrobial resistance, including these:
- A 3.5% reduction in the rate of antimicrobial resistance results in saving $2.7 million per 1,400 patients.
- About 50% of antibiotic use is inappropriate.
- $1.1 billion is spent annually on unnecessary antibiotic prescriptions for upper respiratory infections.
Through Sept. 22, 2010, the web portal will feature a series of four webinars, including one on how to maintain the momentum of an antimicrobial stewardship program, DeChant says.
"They're free, interactive, and anyone can join on our system and listen to a one-hour presentation," he says.
The web portal also seeks input from practicing pharmacists and others to describe their own antimicrobial stewardship programs, which might be featured on-line as success stories, he adds.
"People also can submit questions about the programs, and we have faculty answer them," DeChant says.
"This is a public health threat that is getting worse," DeChant says. "We think every hospital should be involved in some type of antimicrobial stewardship."
Without new drugs to fight drug-resistant microbes, there is little choice but to preserve the medications on the market through vigilant infectious disease control practices and smarter antimicrobial use, Rapp notes.
"We only have two things right now: One is the option of trying to use the drugs we have now better for shorter periods of time and to not use them when we don't need them," Rapp says. "And the other is improved infection control practices."
ASHP's antimicrobial stewardship initiative's ultimate goal is to encourage hospitals and health systems to fight antimicrobial resistance. ASHP wants to see pharmacists move quickly to develop and lead these programs, Rapp says.
Infection control programs in hospitals, nursing homes, homes for the elderly, and elsewhere need to be strengthened, Rapp says.
"Our effort is focusing mainly on hospitals," he says. "And because there are not enough residency training programs to turn out a lot of trained infectious disease pharmacists in a short period of time, we're focusing on educating clinical staff pharmacists," he adds.
Hospitals with few resources for starting a program could at least put together an antimicrobial stewardship team that targets manageable and controllable initiatives, Kaye says.
Hospital pharmacy leaders need to gauge what it will take to produce an acceptable level of antimicrobial stewardship, Cano suggests.
"There are a variety of activities you can do that are very helpful," he adds.
For instance, Cambridge Health Alliance has an antimicrobial stewardship team that meets monthly and includes Cano, who is an infectious disease pharmacist, infectious disease physicians, an infection control practitioner, a microbiologist, and someone from the information technologies department who can help with automating information, Cano says.
Cano and the chief of the infectious diseases department are co-directors of the team.
"We're constantly communicating, planning, and moving forward, doing what we need to do," he says.
"We have an agenda and strategic plan to move forward and reduce costs, increase quality, create efficiency, and increase safety to patients," Cano adds. "We're constantly meeting to discuss cycles of improvement."
References
- Calhoun JH, et al. Multidrug-resistant organisms in military wounds from Iraq and Afghanistan. Clin Orthop Relat Res 2008;466:1356-1362.
- Kang G, et al. Mortality associated with Acinetobacter baumannii complex bacteremia among patients with war-related trauma. Infect Control Hosp Epidemiol 2010;31:92-94.
- Dallo SF, Weitao T. Insights into acinetobacter war-wound infections, biofilms, and control. Adv Skin Wound Care 2010;23:159-174.
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