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Acute bacterial skin and skin structure infections are associated with unnecessary use of broad-spectrum antibiotics, leading to antibiotic resistance. Antimicrobial stewardship programs could be a very effective and useful approach to help stop the alarming trend of antibiotic resistance. Several strategies help optimize outcomes.
The rise in the incidence of acute bacterial skin and skin structure infections (ABSSSI) of late has ushered in a new sense of urgency for health institutions across the United States to tackle the growing problem of antibiotic resistances head-on. Here, antimicrobial stewardship programs are largely viewed as one of the most important strategies for health authorities to more effectively address and hopefully quell the alarming trend of antibiotic resistance.
Formerly referred to as complicated skin and soft tissue infections that include infections with resistance to previously effective antimicrobial drug regimens, ABSSSI is a growing public health threat with far reaching implications including the burden of high direct and indirect costs to both the medical system and society.
“Antimicrobial resistance is a challenging and increasingly alarming medical issue today, and a major concern for international organizations leading the way including the World Health Organization (WHO) and the Centers for Disease Control and Prevention (CDC),” said Timothy R. Pasquale, PharmD, M.B.A., FIDSA, Manager, Clinical Pharmacy Services, Carolinas Medical Center, Carolinas Healthcare System, Charlotte, NC.
“The use of antibiotics is the single most important factor leading to antimicrobial resistance. Although antimicrobial resistance is multifactorial, the implementation of antimicrobial stewardship programs could help combat the issue. The goals of antimicrobial stewardship include promoting the appropriate use of antimicrobials, improving clinical outcomes and helping reduce antimicrobial resistance,” he says.
Antibiotics remain one of the greatest discoveries in modern medicine and according to Dr. Pasquale, antimicrobial stewardship programs could be one of the last resorts that medical authorities have to preserve their efficacy. Some of the main goals of such programs are to incorporate principles that address the appropriate utilization of antibiotics for all specialties and patient groups, which can differ from institution to institution.
Dr. Pasquale and his team of researchers recently conducted a single center, retrospective, observational chart review evaluating the impact of an antimicrobial stewardship program on the management of therapy and hospital resources for patients with ABSSSIs. Information, including patient demographic characteristics, comorbidities, ABSSSI subtype, antibiotic therapy, microbiology surgical interventions, and antimicrobial stewardship program recommendations, was collected from medical records and the antimicrobial stewardship program intervention log. Antimicrobial stewardship program recommendations were divided into five categories, namely, dosage changes, de-escalation, antibiotic regimen change, infectious diseases formal consultation, and other.
For the 62 patients who were included in the study, a total of 85 recommendations were made to attending physicians with an acceptance rate of 95%. Results showed that the most common interventions included dosage changes, de-escalation, antibiotic regimen change, and infectious diseases consultation. These results were then compared with historical data for 1,149 patients with ABSSSI, and showed that the intervention group had a significantly lower mean length of hospital stay. It was also found that the 30-day all-cause readmission rate was significantly lower in the intervention group, but the 30-day ABSSSI readmission rate did not differ significantly between groups.
Although the design of antimicrobial stewardship programs can vary from institution to institution, one of the common goals is to get physicians on the same page in terms of appropriate prescribing and utilization of antibiotics. According to Dr. Pasquale, a multidisciplinary approach is the best setting for optimizing the outcomes of antimicrobial stewardship programs, which the core members typically include a “physician champion” who, in most facilities, is the infectious disease physician and a clinical pharmacist with infectious disease training. Larger healthcare systems that have more of an ingrained antimicrobial stewardship program may have more resources and personnel involved, including information systems specialists, clinical microbiology and infection control professionals, as well as a hospital epidemiologist to coordinate efforts with the core members.
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“The two core members involved in antimicrobial stewardship are the physician as the physician champion, and the pharmacist. They will closely work together and evaluate the patients who are on antibiotics and assess the appropriateness of the antimicrobial for each individual case,” Dr. Pasquale says.
When patients are evaluated for appropriate antibiotic use, Dr. Pasquale sasy that one has to pay special attention to the appropriate selection of the drug, the appropriate dose of the drug, as well as the appropriate duration of therapy. In his evaluation study, Dr. Pasquale utilized a method known as a prospective audit with feedback system. Here, patients are already on antibiotics prescribed by the physician and the pharmacist would look at those patients and assess whether the drug regimen was appropriate for their specific case/infection. The assessment could occur approximately three days after drug initiation, at which time culture results may be ascertained to help decide on the appropriateness of the drug prescribed. This information is critical and could be very helpful in de-escalating the antibiotic regimen that the patient may be on.
According to Dr. Pasquale, while the structure of programs may vary, there are common ways a patient may be reviewed for appropriateness: those who are on three or more antibiotics, those who are on antibiotics for more than three days, and those who are on antibiotics that are on the target list of the task force program. This shortlist may be based and compiled according to the potential for the antibiotic to be inappropriately utilized, cost, or a concern for antimicrobial resistance.
Another stewardship strategy some programs utilize is a formulary restriction and preauthorization. Dr. Pasquale says physicians may choose from a select number of antibiotics, which the antimicrobial stewardship program team must then approve before the drug is administered to the patient.
Evaluating the appropriateness of antibiotic therapy is not only crucial for inpatients but also for the outpatient population as well. According to Dr. Pasquale, this is an area where antimicrobial stewardship needs to tap into as well.
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“Until recently, most antimicrobial stewardship programs are institution based and focus solely on inpatients. If you look at the whole concept of antimicrobial stewardship, to have the greatest impact one needs to look at the entire continuum of care of all patients. Unfortunately, this is lacking in many antimicrobial stewardship programs, which is in part due to lack of resources, ” Dr. Pasquale says.
Looking forward, Dr. Pasquale believes that antimicrobial stewardship programs will be more widely implemented across the United States. The Infectious Disease Society of America, one of the leading organizations in the fight against antimicrobial resistance, promotes the establishment of antimicrobial stewardship programs in every healthcare facility across the United States. The National Action Plan for Combating Antibiotic-resistant Bacteria in response to the Executive Order by President Barack Obama includes a goal to implement antimicrobial stewardship programs. Furthermore, The Centers for Medicare and Medicaid Services are moving toward having antimicrobial stewardship as a condition for participation and accrediting organizations like The Joint Commission are in the process of developing standards.
“I believe that antimicrobial stewardships play a decisive role in helping to curb the rise of antibiotic resistances. These programs are supported by leading organizations like the IDSA and CDC. Some States such as California have even already mandated that institutions have stewardship programs. With the growing quagmire of antibiotic resistances, we need to do all we can to make sure that we have appropriate utilization of our antibiotics,” Dr. Pasquale says.
Disclosures: Dr. Pasquale reports no relevant resources.
Reference: Pasquale TR, et al. Impact of an antimicrobial stewardship program on patients with acute bacterial skin and skin structure infections. Am J Health Syst Pharm. 2014 Jul 1;71(13):1136-9