By: Rexhian Brisku, PharmD Candidate 2021, St. Louis College of Pharmacy at the University of Health Sciences and Pharmacy in St. Louis; Elizabeth Neuner, PharmD, BCPS, BCIDP, Barnes-Jewish Hospital – St. Louis
In 2014, the Centers for Disease Control and Prevention (CDC) released the Core Elements of Hospital Antimicrobial Stewardship Programs (Core Elements) to provide guidance and structure for antimicrobial stewardship programs (ASPs). Regulatory bodies including Centers for Medicare and Medicaid Services and The Joint Commission have since incorporated the Core Elements into accreditation standards. Despite advancements in stewardship, antibiotic resistance is still increasing and remains a public health hazard. The updated 2019 Antibiotic Resistance Threats Report by the CDC estimates 2.8 million cases of resistant infections lead to 35,000 deaths each year.2
The CDC recently updated the original Core Elements to continue optimizing hospital ASPs. The new document provides more granularity and specificity related to ASP activities and identifies priority interventions based on new literature and learned experiences over the past six years. This newsletter provides a summary of the updated 2019 CDC ASP Core Elements.1
1. Hospital Leadership Commitment: The first Core Element discusses the critical role of hospital leadership support for implementing a successful ASP. Priority examples include providing the ASP with time, resources and routine communication with executive leadership. Literature is emerging with recommendations for minimal ASP fulltime equivalent (FTE)-to-bed staffing ratios. A 2018 cross-sectional survey of 208 hospitals examined the relationship between ASP staffing levels and ASP effectiveness which they defined as a positive survey response to at least one of the following: established cost saving, decreased antibiotic utilization and decreased multi-drug resistance rates of organisms within the last four years.3 Every 0.5 increase in combined physician and pharmacist FTE availability predicted a 1.48-fold increase in ASP effectiveness (95% confidence interval, 1.06-2.07).3
2. Accountability: This Core Element emphasizes the need for a designated leader responsible for management and outcomes and highlights the effectiveness of a co-leadership model between pharmacists and physicians. The 2019 National Healthcare Safety Network (NHSN) Hospital Survey report of all U.S hospitals with stewardship programs, 59% utilize the co-leadership model.1
3. Pharmacy Experience: The previous “Drug Experience” Core Element is now referred to as “Pharmacy Experience” to highlight the importance of pharmacy engagement for the success of a stewardship program.1 A 2016 commentary on behalf of the Society of Infectious Diseases Pharmacists (SIDP) and the American Society of Health-System Pharmacists (ASHP) emphasizes the role of pharmacists, especially those trained in infectious diseases or antimicrobial stewardship, as essential.4
4. Action: This section was expanded to include evidence-based recommendations of effective ASP actions. The priority actions are prospective audit and feedback (PAF review of antibiotic therapy by an expert in antibiotic use), preauthorization (PA approval required prior to use of certain antibiotics) and facility-specific treatment guidelines.1 Several recent studies provide rationale for prioritizing PAF and PA by demonstrating the effectiveness in reducing overall antimicrobial use and improving appropriateness. A 2017 quasi-experimental, crossover trial comparing PAF and PA concluded that the incorporation of PAF had a more profound effect on reducing antimicrobial days of therapy.5 However, guideline adherence was found to be higher on day one in the PA group. The CDC considers both actions “foundational” for ASPs as they are complementary; PA optimizes initial empiric therapy and PAF reassesses continued therapy.1 Facility specific treatment guidelines can augment the effectiveness of both PAF and PA through optimizing antibiotic selection and therapy duration. ASPs should focus on the most common infections (e.g. lower respiratory tract, urinary tract, skin and soft tissue, etc.) and consider other infection-based interventions for sepsis, S. aureus and C. difficile infections.1
The usefulness of antibiotic timeouts, designated reassessment of antibiotic therapy by providers, is reframed as a supplemental strategy.1 Limited data suggests timeouts may improve appropriateness, but not reduce overall antimicrobial use. Therefore, this strategy should not replace PAF.6
Other supplemental actions organized around different ASP key stakeholders (pharmacy, microbiology and nursing) may help improve antibiotic prescribing, duration and safety. Pharmacy focused interventions include requiring indications, IV to PO switches, dose optimizations, alerts for duplicate therapy or drug interactions, and automatic stop orders. Microbiology-based interventions involve selective and cascading susceptibility reporting and “nudge” based interpretive comments.7 ASP actions for nursing discuss optimizing culture acquisition.
5. Tracking: The CDC recommends that ASPs track a variety of different measures to identify intervention opportunities and assess the impact of their efforts. It is highly recommended to submit antimicrobial use data to the NHSN Antimicrobial Use module to allow benchmarking with the use of the standardized antimicrobial administration ratio.8 Tracking of both outcomes (including C. difficile infections, resistance and financial impact) and process metrics is also recommended. Priority process measures include intervention types and acceptance rates, ensuring PA does not delay therapy and adherence to institution specific treatment guidelines.
6. Reporting: The CDC continues to recommend ASPs report antimicrobial use and resistance to hospital staff and leaders on a regular basis. Provider-level feedback is an effective outpatient ASP strategy; however, limited data exists for hospital ASPs given the complexity of inpatient prescribing.
7. Education: Antimicrobial stewardship education is important for many disciplines including prescribers, nurses and pharmacists. A variety of ways to provide education exist including a case-based approach through PAF or PA. For pharmacists specifically, SIDP, ASHP and CDC developed a campaign on the 5 Ways Hospital Pharmacists Can Be Antibiotic Aware. Hospital pharmacists should (1) verify penicillin allergies, (2) avoid duplicative anaerobic coverage, (3) reassess antibiotic therapy, (4) avoid treatment of asymptomatic bacteriuria and (5) use the shortest effective duration possible. Additional campaign material can be found at www.sidp.org/AMRchallenge.
In conclusion, as antimicrobial resistance continues to evolve, so too must antimicrobial stewardship practices. Hospital ASPs should work to incorporate the updated Core Elements to combat current and developing antibiotic resistance threats.