The American Hospital Association (AHA) has created an online antimicrobial stewardship kit as part of its list of the top five hospital-based procedures or interventions that need to be reviewed and discussed by patients and physicians.
"The toolkit is a collection of resources available for health care organizations, patients, and physicians to develop and maintain an antimicrobial stewardship program," says John Combes, MD, senior vice president of AHA and president and chief operating officer of the Center for Healthcare Governance in Chicago, IL.
The AHA pared down its advice on antibiotic stewardship to three general principles.
- Do not give antibiotics when they are not needed.
- Give the appropriate amount of antibiotics at the appropriate time.
- Give the right antibiotics.
Rather than reinventing the wheel, the AHA wisely drew on Centers for Disease Control and Prevention guidance and information from other knowledge leaders like the Association for Professionals in Infection Control and Epidemiology (APIC). The main sections include a user guide that introduces the toolkit; a CDC readiness checklist; a resource section for hospitals and health
systems; clinician implementation guides and tools, and patient resources. AHA advised sharing the CDC readiness checklist with senior management, quality leaders, purchasing directors, clinic managers, nurse managers, key physician leaders, risk managers, pharmacy leaders, infection preventionists and hospital epidemiologists, laboratory staff and information technology staff.
For ease of use, the AHA toolkit is divided into two sections, one for those just beginning a program, the other for those who wish to enhance an existing program. Clinician resources in the kit include webinars, clinical evidence supporting appropriate use of antibiotics, implementation guides and related articles. The patient resources section includes frequently asked questions, pamphlets and handouts on how patients can best engage in their care, and other resources on appropriate use of antibiotics.
In this area, the toolkit includes a new APIC infographic (http://bit.ly/1BEH4Zr) that explains to patients and consumers the key points of preserving antibiotics and why it is important not to "pressure" physicians for them if they are not needed. The handout touches on the basics of drug
resistance and reminds patients that antibiotics can have side effects and create "superbugs." APIC also urges patients to ask these five questions to make sure they need a prescription.
- Do I really need an antibiotic?
- Can I get better without this antibiotic?
- What side effects or drug reactions can I expect?
- What side effects should I report to you?
- How do you know what kind of infection I have? I understand antibiotics won’t work for viral infections"
AHA kit is designed for electronic use
The eight-page AHA toolkit is intended to be viewed electronically (http://bit.ly/VTeDIb) and contains links to additional tools and information. For example, the CDC Checklist for Core Elements of Hospital Antibiotic Stewardship Programs (http://1.usa.gov/1l236QG) — a four-page tool — is available as a link.
"The toolkit has various components to help implement an antimicrobial stewardship program," Combes says. "All organizations need to take the readiness assessment as a first step."
The readiness assessment checklist includes questions such as:
- Does your facility have a formal, written statement of support from leadership that supports efforts to improve antibiotic use?
- Does your facility receive any budgeted financial support for antibiotic stewardship activities (e.g., support for salary, training, or IT support)?
- The CDC summarizes the core elements of hospital antibiotic stewardship programs as containing these seven components:
- Leadership Commitment: Dedicating necessary human, financial and information technology resources
- Accountability: Appointing a single leader responsible for program outcomes. Experience with successful programs show that a physician leader is effective
- Drug Expertise: Appointing a single pharmacist leader responsible for working to improve antibiotic use.
- Action: Implementing at least one recommended action, such as systemic evaluation of ongoing treatment need after a set period of initial treatment (i.e. "antibiotic time out" after 48 hours)
- Tracking: Monitoring antibiotic prescribing and resistance patterns
- Reporting: Regular reporting information on antibiotic use and resistance to doctors, nurses and relevant staff
- Education: Educating clinicians about resistance and optimal prescribing
Regarding education, the CDC recommends providing regular updates on antibiotic prescribing, antibiotic resistance, and infectious disease management that address both national and local issues. Sharing facility-specific information on antibiotic use can help motivate improved prescribing, particularly if wide variations in patterns of use exist among similar patient care locations.
"After taking these steps, what becomes important is engaging physicians and showing them clinical evidence of what antimicrobial stewardship could do for the organization and their practices,"
Combes says. "I think all good antibiotic usage should be targeted and limited — at least at the institutional level where physicians are practicing."
The current antimicrobial thinking is targeted use of drugs for limited duration, he adds. "Make sure you have a very narrow range of use," he says. "Before you get a culture back, use an antibiotic that has a pattern of susceptibility that is similar to organisms seen at your institution. Then when you get the culture back, narrow it down to a drug that is specific for that infection and use it for the shortest time recommended."
The CDC recommends that clinicians specify the dose, duration and indication for all courses of antibiotics so they are readily identifiable. Make this information accessible to help ensure that antibiotics are modified as needed and/or discontinued in a timely manner. Develop facility-specific treatment recommendations based on national guidelines, using local susceptibilities and formulary options to optimize antibiotic selection and duration for common indications like community-acquired pneumonia, urinary tract infection, intra-abdominal infections, skin and soft tissue infections and surgical prophylaxis.
