Rounding up resistance can lower costs, too

ICP, pharmacy, doctor teams review antibiotic use

Infection control professionals and their clinical colleagues are finding that implementing antibiotic "rounds" programs can cut costs and lower the prevalence of resistance pathogens like vancomycin-resistant enterococci (VRE).

With increasing calls to clamp down on use of antibiotics to curb the rise of resistant pathogens, the multidisciplinary rounds approach is emerging as a practical and cost-effective strategy.

For example, clinicians at Our Lady of Lourdes Medical Center in Camden, NJ, implemented a weekly antibiotic rounds program in May 1997 to reduce unnecessary use of vancomycin and promote use of penicillin-like antimicrobials rather than third-generation cephalosporins. The result has been a reduced VRE rate from 2.5 cases per 1,000 patient days in February of 1997 to less than one VRE case per 1,000 patient days by February of 1998.

"For the first half of 1998, we've found considerably lower rates," says Georgeanne Ryan, MLT, BBA, infection control practitioner at the medical center.

Indeed, when the rounds program was discontinued temporarily late last year due to holidays and scheduling conflicts, both use of vancomycin and VRE rates surged up, she notes.

"We suspect that was because we didn't do rounds in November," she notes. "Now that we are continuing to do rounds again consistently the rates have gone down."

In addition to Ryan, the weekly rounds team includes an infectious disease physician and a clinical pharmacist. One of the more important aspects of the program is use of a confidential communication form so that the infectious disease physician can recommend antibiotic changes to colleagues. (See form, p. 137.) The form is added as an advisory to the progress notes section of the patient chart in a sealed envelope, but it is not considered part of the permanent patient record and compliance with the recommendations is not mandatory.

^{Linking up doctors}

"It has helped to bring in a physician-to-physician type of link," explains Thomas Turco, PharmD, assistant director of the medical center pharmacy. "Most of the time [the physicians] have taken it and made some changes, but it is not confrontational and nobody else has to know about the content of the note."

Examples of recommended interventions include discontinuing antimicrobial therapy, narrowing the spectrum of coverage, and/or changing to appropriate oral therapy. (See bar chart, left.) For example, the rounds team may recommend a discontinuation of therapy if it appears the risk of infection can be ruled out. Likewise, a switch to oral medication may be recommended if it appears intravenous therapy is no longer warranted, he adds.

"If you eliminate the IV, you eliminate the complications of phlebitis and so forth and you probably eliminate the more expensive IV agent," Turco says, adding that the switch to oral therapy may also lead to a shorter lengths of stay.

Overall, the rounds program has resulted in a 25% reduction in the use of vancomycin and third-generation cephalosporins. In addition to reduced drug use and lowered VRE levels, the project demonstrated cost savings conservatively estimated at $7,619 over the first 10 months. The figure is a minimal estimate because it represents only the costs of the drugs and the savings reflected by discontinuing therapy or switching to a less expensive antimicrobial, Turco says.

The estimate does not take into account the money saved by pharmacy and clinical staff to prepare and administer medications, he explains.

"In about 39% of our interventions, we're actually to discontinue therapy altogether," he noted. "In those you are essentially eliminating the cost of the medication, along with all the time that is needed for preparation and administration of the medication. We probably don't have enough numbers or sophisticated computer systems to really look at this, but there is also an affect, hopefully, on length of stay."

^{WA hospital reaps savings, too}

A similar program implemented at Harrison Memorial Hospital in Bremerton, WA, resulted in an estimated cost savings of more than $107,000 annually, adds Betty Dunaway, RN, MA, CIC, director of infection control and epidemiology at the facility. A key intervention since the antibiotic rounds program was implemented two years ago has been cutting standard administration of Rocephin - a third-generation cephalosporin - from two grams to one whenever clinically appropriate, she notes.

"One of the things that we were really pleased with was the fact that we had a cost reduction of all antibiotics," she says. "Costs were rising, but once we started rounding and started our antibiotic program our costs are practically down to what they were in 1990." (See graph, above)

The program was implemented as a proactive measure due to an increase in VRE in area hospitals, she says, noting that it the team also includes a pharmacist, an infectious disease physician and a microbiologist. Patients selected for review include are those that have been on antibiotic therapy for more than 72 hours and all patients on multiple antibiotic treatment. In addition to ensuring that vancomycin is being used appropriately, the team assesses whether the infection and the antimicrobial therapy appear to be an appropriate match.

"We probably look at least a dozen patients each time we round," she says. "The main thing I am looking for is cultures matching up with the antibiotic."

One result of the program has been adoption of an automatic stop order after three days on IV antibiotics, she says. In general, however, any interventions are presented as recommendations for the attending physicians consideration.

"When we do look at a medical record and we feel than an antibiotic is inappropriate or needs to be changed, there is a recommendation left on the chart," Dunaway says. "In follow-up, we're finding out that probably about 99% of the physicians do take the recommendations."

Another benefit to such programs is the educational opportunities, she adds.

"It's an opportunity to pull those staff nurses in while you are there evaluating a medical record," she says. "Visibility is really a big thing, and there is an opportunity for staff to ask questions."

Indeed, the educational aspect of the antibiotic rounds approach may have broader implications beyond the immediate clinical intervention, Ryan adds.

"Maybe we can impact on the reduction of antibiotic usage from an outpatient perspective because a lot of the staff physicians have clinics and have outpatient facilities in offices," she says.