In 2006, infectious disease specialists and pharmacists at Johns Hopkins Bayview Medical Center in Baltimore took a look at the pharmacy budget and were jarred by the numbers.
“The proportion of the pharmacy budget that was antimicrobials was much larger than we would expect,” says Jonathan Zenilman, MD, chief of infectious diseases at Bayview.
The pharmacy and ID teams implemented antibiotic stewardship tools, including medication reassessments after two or three days and quicker conversion to oral drugs when appropriate. They also did something that was fairly new at the time: A hospitalist was incorporated into the team. The tactic was employed out of need—the ID department was stretched too thin—but it made perfect sense, Dr. Zenilman says. Most of the patients seen by hospitalists have bread-and-butter conditions that comprise a lot of the center’s antibiotic use.
“Patients on a typical hospital medicine series are not on advanced antifungals and complicated antibiotic regimens,” he says.
The arrangement worked: The center achieved a more than 50% reduction in the main target drug, Zosyn, and a hospitalist is still typically part of the antibiotic stewardship team.
That might have been a new concept then, but fast forward a decade: ID and public health experts are increasingly seeing hospitalists as central to the effort to limit antibiotic overuse and stall the development of drug resistance in antimicrobial organisms.
Now, SHM is about to launch a campaign to get more hospitalists to see themselves as central to that effort. SHM will formally kick off the “Fight the Resistance” campaign on November 9. It’s an awareness and behavior change campaign that builds on SHM’s participation in a White House forum on antibiotic resistance that was held in June.
“We wanted to not only enhance awareness among hospitalists about what appropriate antimicrobial prescribing is, but also to change behaviors and ultimately change culture to facilitate appropriate antibiotic use,” says Jenna Goldstein, director of SHM’s Center for Hospital Innovation and Improvement (CHII), who is leading the initiative along with Mobola Owolabi, SHM project manager.
The society will provide educational inserts hospitalists can use at their hospitals, as well as downloadable posters that will help raise awareness on appropriate antibiotic use. The campaign will be highlighted in SHM’s online and social media presence.
Hospitalists will be asked to make behavior changes in their antibiotic-related practices that will promote better stewardship, such as taking an antibiotic “timeout” during which usage is revisited and changed or discontinued if antibiotic use is not appropriate.
“We’re specifically asking hospitalists to engage in behavior changes and we plan to assess outcomes and results after implementation,” Goldstein says. “Our ultimate goal, although we realize this is a much longer-term goal and certainly more arduous to measure, is to change the culture in the hospital related to prescribing, so that hospitalists are prescribing only when appropriate, only when there’s an indicated infection, and according to the evidence base for prescribing antimicrobials for their patients.”
Future plans will include developing a mentored implementation program in which SHM will provide guidance for hospitalists who want to develop or improve a stewardship program at their hospital. The guidance will be based in part on the CDC’s “Core Elements of Hospital Antibiotic Stewardship Programs,” a kind of guidebook on antibiotic stewardship.1
Eric Howell, MD, SFHM, director of the collaborative inpatient medicine service at Bayview, associate professor of medicine at Johns Hopkins University School of Medicine, and CHII’s senior physician advisor, says it’s time for hospitalists to take on a bigger role.
“Doing ‘just in case’ antibiotics is really not appropriate and should be strongly discouraged, unless the risks are very high for a specific patient,” he says. A past president of SHM, Dr. Howell has long advocated that hospitalists take the time to explain the risk of excessive antibiotic use to their patients, even on a busy day.
“It’s our duty as physicians to make sure our patients get the best care possible, and often that means the physicians themselves have to do the educating,” he says. “I would say that, in general, it doesn’t take that much time. Having a conversation with your patient to educate them about anything—heart failure, diabetes, appropriate antibiotics—must be built into the care that we provide our patients somehow.”
That communication doesn’t necessarily have to be performed by the hospitalist, he notes. The pharmacist, nurse, or written material can relay this information. But somewhere along the line, he says, the antibiotic education must happen.
SHM’s initiative should help, simply because “knowledge is good,” says Dr. Zenilman, the ID expert at Hopkins Bayview. Key to success, he says, will be what happens when hospitalists are taking care of a patient—will they actually be willing to cut their regimens?
“People overuse antibiotics, sometimes not out of education issues, but because they’re anxious,” Dr. Zenilman says. “The more challenging part is getting people to deal with the uncertainty and recognizing intuitively that overuse has enormous complications.”
The literature is now replete with studies showing how antibiotic stewardship measures help curb resistance, eliminate incorrect antibiotic prescribing, lower antibiotic use, and lower costs.
A web-based program was projected to save almost $400,000 a year linked to restricted antibiotic use at Johns Hopkins, according to a 2008 study.2
In Canada, according to a 2007 study, a program including recommendations for alternative drugs and shorter, guideline-based treatment durations helped reduce Clostridium difficile infections by 60% over a two-year period.3
An analysis published in August, using data from the CDC’s National Healthcare Safety Network and Emerging Infections Program, concluded that a nationwide infection control and antibiotic stewardship intervention could, over five years, avoid an estimated 619,000 hospital-acquired infections from carbapenem-resistant Enterobacteriaceae, multidrug-resistant Pseudomonas aeruginosa, invasive methicillin-resistant Staphylococcus aureus (MRSA), or C. diff.4
In spite of the evidence, preliminary results of a recent SHM survey on antibiotic stewardship found very little support, in terms of money and protected time, for hospitalists to be involved in antibiotic stewardship programs.
UM’s Success Story
A kind of microcosm of what is possible can be seen at the University of Michigan. There, Scott Flanders, MD, MHM, clinical professor of internal medicine and past president of SHM, has led an effort, along with the CDC and the Institute for Healthcare Improvement, to look at hospitalist-led interventions for smarter antimicrobial use.
Hospitalists in several programs around the country were asked to focus on a few key improvement strategies that are believed to improve use. For instance, when guidelines give a range of duration of dosing, physicians often lean toward the higher end (when the range is seven to 21 days, the default was typically closer to 21), even when that might not be necessary in a given situation. So, more specific guidelines for common situations were applied.
Hospitalists also worked to improve documentation to make antibiotic use more visible at the point of care: which drug it is, when it was started, what day of therapy it is that day, how many more days are left.
An antibiotic “timeout” at 48 to 72 hours was implemented to determine whether the treatment course should be maintained, changed, or eliminated.
The idea was for hospitalists to track this as part of the usual care process.
“We didn’t want people to create whole new systems to do these things,” says Dr. Flanders, who has consulted with SHM for its stewardship initiative. “We wanted people, for example, to use their multidisciplinary rounds that they were already having to just add one thing to the checklist.”
The process was shown to be workable. All steps of the stewardship protocol were performed 70% of the time after the initiative began, compared with just 20% of the time before it began, Dr. Flanders says. Additionally, about 25% of patients had a “significant and important” change made to their antibiotic treatment following the “timeout.”
“During this timeout, a lot of action happened,” Dr. Flanders says. More study is needed to show exactly how much of a change occurred and whether it led to cost savings, he says, but “I suspect it will.”
Arjun Srinivasan, MD, associate director for healthcare-associated infection prevention programs at the CDC, says he is eager to continue to work with SHM on its antibiotic stewardship efforts, but he cautions that hospitalists should not try to do too much too quickly in implementing change.
“Success generally comes from starting small, from starting with a focused approach to something that you know is a problem in your facility,” Dr. Srinivasan says. “When you try to delve into everything all at once, you can very quickly get overwhelmed.”
Although smaller centers might have less manpower and face a bigger challenge in leading a stewardship program, it can be done, he says.
“We see some very small hospitals that have fantastic stewardship programs and some very small hospitals that are struggling,” he says. “We know it’s doable across the spectrum of the sizes of hospital.”
Hospitalists, he adds, “are the tip of the spear. They are probably prescribing most of the antibiotics [for inpatients] … and diagnosing most of the infections. So arming them with the information they need, working with them to develop a process that makes prescribing optimal and most efficient is obviously hugely beneficial.
“You’re going to have a tremendous impact by reaching that particular group.”
Tom Collins is a freelance writer in South Florida.
- Centers for Disease Control and Prevention. Core elements of hospital antibiotic stewardship programs. May 7, 2015. Accessed October 6, 2015.
- Agwu AL, Lee CK, Jain SK. A World Wide Web-based antimicrobial stewardship program improves efficiency, communication, and user satisfaction and reduces cost in a tertiary care pediatric medical center. Clin Infect Dis. 2008 Sep 15;47(6):747-753.
- Valiquette L, Cossette B, Garant MP, Diab H, Pépin J. Impact of a reduction in the use of high-risk antibiotics on the course of an epidemic of Clostridium difficile-associated disease caused by the hypervirulent NAP1/027 strain. Clin Infect Dis. 2007;45 Suppl 2:S112-S121.
- Slayton RB, Toth D, Lee BY, et al. Vital signs: estimated effects of a coordinated approach for action to reduce antibiotic-resistant infections in health care facilities - United States. MMWR Morb Mortal Wkly Rep. 2015;64(30):826-831.