What’s New in the Patient Safety World
August 2016
Some Reassurance on Antibiotic Stewardship
Last month we
discussed new guidelines on antibiotic stewardship (see our July 2016 What's New in the Patient Safety World column “NQF/CDC
Guideline on Antibiotic Stewardship”) and in our several other prior columns on antibiotic stewardship
listed below we’ve noted the overprescription of
antibiotics for inappropriate indications, both in hospitals and ambulatory
settings.
One such category
where inappropriate antibiotic prescribing is rampant is the upper respiratory
tract infection (RTI) that is usually self-limited and many of which are caused
by viruses so are not amenable to antibiotic treatment. Many primary care
practitioners remain concerned that failure to use antibiotics in such cases
may lead to adverse consequences in their patients. They often have the
impression that the primary reason for avoiding antibiotic prescribing is to
prevent development of antibiotic-resistant organisms and that such concern
applies to populations rather than to their individual patients. In fact,
that’s not true as we discussed in our November 2015 What's
New in the Patient Safety World column “Medications
Most Likely to Harm the Elderly Are…” that the medications most likely to
harm the elderly are antibiotics.
But it would be
reassuring to see a study showing that avoidance of antibiotics in such cases
is, in fact, safe. So a recent study done in 601 general practices in the UK
provides such welcome reassurance. Researchers used data from the UK Clinical
Practice Research Datalink (Gulliford 2016).
They found that general practices that
adopt a policy to reduce antibiotic prescribing for RTIs might expect a slight
increase in the incidence of treatable pneumonia and peritonsillar
abscess. However, there was no increase likely in mastoiditis, empyema,
bacterial meningitis, intracranial abscess, or Lemierre’s
syndrome.
They estimate that
if a general practice with an average list size of 7000 patients reduces the
proportion of RTI consultations with antibiotics prescribed by 10%, then it
might observe 1.1 more cases of pneumonia each year and 0.9 more cases of peritonsillar abscess each decade. They conclude that even
a substantial reduction in antibiotic prescribing was predicted to be
associated with only a small increase in numbers of cases observed overall, but
caution might be required in subgroups at higher risk of pneumonia.
An accompanying editorial (Del Mar 2016) also finds some reassurance in these findings. Some rapid response letters (Rapid Response 2016) note the importance of adequate early followup and cooperation of parents when treating pediatric patients. But another of the rapid response letters reveals a critical root cause of overprescribing antibiotics – the already harried general practitioner fears his workday will become overburdened by patients returning for an additional evaluation.
In our July 2016 What's New in the Patient Safety World column “NQF/CDC Guideline on Antibiotic Stewardship”) we noted that CMS has announced that hospitals will be required to have antibiotic stewardship programs and demonstrate that they have reduced inappropriate antibiotic usage (CMS 2016). Now The Joint Commission has also revised its standard regarding antibiotic stewardship, effective January 1, 2017 (TJC, 2016).
Elements of the new
TJC standard for include:
- Establishing antimicrobial stewardship as an organizational priority
- Educating staff and practitioners involved in ordering, dispensing
and monitoring antibiotics about antibiotic resistance and good
stewardship practices both at the time of hiring or credentialing and
periodically thereafter
- Educating patients and families about appropriate use of
antimicrobials
- Establishing an antimicrobial stewardship team, including an
infectious disease physician, infection preventionist(s),
pharmacist(s), and practitioner(s) (note that they will allow part-time
staff and even telemedicine consultants to fulfill some of the roles)
- Ensuring the core elements of a good antibiotic stewardship program
are in place (see below)
- Ensuring the antimicrobial stewardship program uses
organization-approved multidisciplinary protocols (for example, policies
and procedures for things like formulary restrictions, C. diff treatment,
parenteral to oral conversion, appropriateness of antibiotics for
community acquired pneumonia, etc.)
- Gathering, analyzing and reporting data on the program
- Takes action on improvement opportunities identified in its
antimicrobial stewardship program
As a reminder, the
seven CDC-defined core elements (CDC
2016) of a comprehensive antibiotic
stewardship program are:
- Leadership Commitment: Dedicate necessary human, financial, and information technology resources.
- Accountability: Appoint a single leader responsible for program outcomes who is accountable to an executive-level or patient quality-focused hospital committee. Experience with successful programs shows that a physician leader is effective.
- Drug Expertise: Appoint a single pharmacist leader responsible for working to improve antibiotic use.
- Action: Implement 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: Monitor process measures (e.g., adherence to facility-specific guidelines, time to initiation or de-escalation), impact on patients (e.g., Clostridium difficile infections, antibiotic-related adverse effects and toxicity), antibiotic use, and resistance.
- Reporting: Report the above information regularly to doctors, nurses, and relevant staff.
- Education: Educate clinicians about disease state management, resistance, and optimal prescribing.
The TJC prebulication document also provides links to some useful tools, such as materials for educating patients and their families
See our columns listed below for ways to deal with the problem of inappropriate antibiotic prescribing and antibiotic stewardship programs both in the hospital and the ambulatory setting.
Some of our prior columns on antibiotic stewardship:
- October 14, 2014 “Antibiotic
Stewardship”
- November 2015 “Medications
Most Likely to Harm the Elderly Are…”
- July 2016 “NQF/CDC
Guideline on Antibiotic Stewardship”
References:
Gulliford MC, Moore MV, Little P, et al. Safety of reduced antibiotic prescribing for self limiting respiratory tract infections in primary care: cohort study using electronic health records. BMJ 2016; 354: i3410 (Published 04 July 2016)
http://www.bmj.com/content/354/bmj.i3410
Del Mar C. Antibiotics for acute respiratory tract infections in primary care. BMJ 2016; 354: i3482 (Published 05 July 2016)
http://www.bmj.com/content/354/bmj.i3482
Rapid Responses. Antibiotics for acute respiratory tract infections in primary care. BMJ 2016; 354: i3482 (Published 05 July 2016)
http://www.bmj.com/content/354/bmj.i3482/rapid-responses
CMS (Centers for Medicare & Medicaid Services). CMS Issues Proposed Rule that Prohibits Discrimination, Reduces Hospital-Acquired Conditions, and Promotes Antibiotic Stewardship in Hospitals. June 13, 2016
https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-06-13.html
TJC (The Joint Commission). New Antimicrobial Stewardship Standard (Prepublication Requirements). June 24, 2016
https://www.jointcommission.org/assets/1/6/HAP-CAH_Antimicrobial_Prepub.pdf
CDC (Centers for Disease Control and Prevention). Core Elements of Hospital Antibiotic Stewardship Programs. Page last updated: May 25, 2016
http://www.cdc.gov/getsmart/healthcare/implementation/core-elements.html
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