Blueprints for Antimicrobial Stewardship

Kristi Kuper, PharmD, BCPS, received her Doctor of Pharmacy degree from the University of Nebraska Medical Center and completed a pharmacy practice residency at the James A. Haley Veterans Hospital in Tampa, Florida. She is credentialed as a board-certified pharmacotherapy specialist. She has more than a decade of experience as an infectious diseases/antimicrobial stewardship pharmacist. She is recognized as a national pharmacist expert on antimicrobial stewardship, with a specific focus on program implementation in resource-challenged settings. To date, she has worked in various capacities with more than 500 hospitals nationwide. Dr. Kuper has served on several national antibiotic stewardship committees, including several CDC workgroups. She was an invited attendee at the White House Forum on Antibiotic Stewardship in June 2015 and was also a contributor to the National Quality Forum’s antibiotic stewardship playbook, which is a nationally recognized antibiotic stewardship resource. She has more than 40 peer-reviewed posters and publications. As senior clinical manager of infectious diseases at Vizient’s Center for Pharmacy Practice Excellence, Dr. Kuper is primarily responsible for working with Vizient members to assist with the development and implementation of antimicrobial stewardship programs as well as monitoring trends in the prevention and treatment of infectious diseases.

Can you tell me a bit about Vizient and its activities related to antimicrobial stewardship?

Vizient is the nation’s leading health care performance improvement company. We serve more than half of the health care organizations across the United States—from large integrated delivery networks and academic medical centers to community hospitals, pediatric facilities, and non-acute care providers.

Because of the large diversity of our organization, we have the ability to interact with hospitals in a variety of ways around stewardship. This ranges from one-to-one engagements through our advisory solutions teams (i.e., consulting services) where our consultants work directly with individual hospitals and health systems to manage antibiotic use, to one-to-many engagements where we deliver educational programs to hundreds of hospitals on key topics related to antibiotic stewardship and work with smaller groups as part of our performance improvement collaboratives.

Finally, we also have an antibiotic stewardship committee that comprises 30 infectious diseases physicians and pharmacists who meet monthly and are working on programs and conducting research on antibiotic stewardship. This group is composed of our Vizient University HealthSystem Consortium members, who represent 95 percent of the nation’s academic medical centers.

What are some of the key components of successful antimicrobial stewardship programs?

Several years ago, the CDC came out with that they call the Core Elements of Antibiotic Stewardship. They have four sets of elements for hospitals, small and critical access hospitals, nursing homes, and ambulatory care, respectively. These are really the blueprints for what are considered a successful stewardship program. They each vary a little bit, but I think all of them have this basic first tenet, which is that successful stewardship starts at the top—you need good leadership from a physician and pharmacist who have experience in infectious diseases and can influence change among others. Leadership at the highest levels of the organization is also beneficial because there are times when the program may require financial or senior level medical staff support and this person  (usually at the C-suite level) is typically in the best position to enable those resources. I always say it is a good sign when your hospital CEO knows what the term “antibiotic stewardship” means.

It is important to have a set of interventions for improving antibiotic use that are performed consistently and accurately as well as educational programs or resources available that can help educate clinicians and support personnel. Also, antibiotic stewardship should be something that everyone who interacts with a patient thinks about. For example, nurses can be great allies in helping promote antibiotic use. They can perform a simple evaluation about a patient’s antibiotic use that might prompt a physician to look more closely at the patient’s antibiotic regimen. 

Finally, you should have a way to track metrics and a process to use these metrics for performance improvement. 

How can hospitals measure the success of their antimicrobial stewardship programs?

There are many different ways that hospitals can track the success of their antibiotic stewardship programs. Many track antibiotic utilization on a monthly basis by individual drug or drug class and then report this as a function of census. For example, antibiotic days of therapy per 1,000 patient days. In nursing homes, this can be more difficult to track, so it might be easier to look at antibiotic starts instead. About a quarter of the nation’s hospitals can report their antibiotic use data into the National Healthcare Safety Network’s Antibiotic Use and Resistance Module. 

Other measurements that can be used to track the success of an antibiotic stewardship program include number of interventions (e.g., how many patients have their antibiotic therapy streamlined or narrowed, how many patients had their medications appropriately adjusted for kidney dysfunction, or how many patients were converted from intravenous to oral therapy). Another good metric that is associated with improved antibiotic use is the rate of Clostridiodes (Clostridium) difficile infections. Good antibiotic stewardship use has been directly correlated with a reduction in C. difficile infections. 

Ideally, we would like to be able to also track metrics such as mortality, hospital readmissions, and antibiotic resistance, but these can be more difficult to track in the acute care setting since these events often happen after the patient leaves the hospital. 

What is the most common pitfall that hospitals encounter when implementing antimicrobial stewardship programs?

They make it just about reducing costs or they are under-resourced, meaning they don’t have the appropriate pharmacist and physician resources available to support the program. Antibiotic stewardship programs should be seen as having the primary goal of patient safety. As the old saying goes, “If you do the right thing, cost will follow.” 

How are technological advances impacting antimicrobial stewardship? 

Integrating technology into your stewardship program can make a substantial difference in improving the quality of the program and extending the human resources, but it has to be done well. 

Technology can extend the reach of the program and can be used to engage other personnel, outside of just the antibiotic stewardship team, to perform antibiotic interventions. For example, alerts can be built into the electronic health record that can prompt a physician to evaluate a patient’s antibiotic therapy at a specific point in time (e.g., 48 to 72 hours). This is referred to as an antibiotic time-out. Alerts can also be built into an electronic health record to prompt a nurse to speak to a physician about converting a patient who has other active oral medications on their profile and is tolerating an oral diet to oral therapy. 

Technology can also be used to help communicate the results of rapid or traditional antibiotic-stewardship-testing resources to decision makers so that the benefits of these tests can be realized in a timely manner. Finally, technology can help automate the tracking and reporting of metrics of antibiotic use, which saves a tremendous amount of time. 

What advice do you have for hospitals looking to improve their antimicrobial stewardship programs?

Start by having the basics in place and doing them well. I always say, “Walk before you run.” It is also important to not only have metrics but to also set goals for those metrics and evaluate them periodically. If you are not meeting those metrics, conduct an assessment of why, and use these findings to improve quality. Also, take the time to understand what other activities in the hospital are ongoing that the stewardship program could connect with in order to be synergistic. For example, take time to speak with infection prevention, quality, and microbiology specialists to understand what their priorities and programs are and to think about ways that you can support each other’s programs. Finally advertise your program’s successes. I think sometimes we’re focused on what is being done wrong, but it’s important to take time to recognize when people or prescribers are doing the right thing. 

What is your outlook for the future of antimicrobial stewardship?

Extremely positive! In one way, shape, or form, antibiotic stewardship is now recognized as an important patient safety program in every care area. The interest in stewardship in the ambulatory setting has just been invigorated by the Joint Commission’s Medication Management Standards for Ambulatory Health Care, which goes into effect on January 1, 2020.