Infection Control Today

OCT 2018

ICT delivers to infection preventionists & their colleagues in the operating room, sterile processing/central sterile, environmental services & materials management, timely & relevant news, trends & information impacting the profession & the industry

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18 ICT October 2018 www.infectioncontroltoday.com decision support, including prospective audit and feedback and, as an important component of any program, education of the prescribing staff (Rice 2018). A s Rice (2018) obser ves, "Limiting antimicrobial formularies and restricting the use of certain antibiotics is a technique that has been used for decades. In many cases, the limitations have been dictated by cost, with the motivation to decrease the overall hospital spend on antibiotics. In general, because newer drugs tended to be more expensive than older drugs, and having a broader spectrum of activity, these practices in effect resulted in promoting more narrow- spectrum alternatives." Antimicrobial cycling, Rice (2018) explains, "refers to practices in which there are predetermined changes in empirical usage of antibiotics, usually within a certain unit of a hospital, that occur according to a prespecifed time schedule. The goal is to avoid prolonged use of a single class of antibiotics and thereby the selection of resistance to that class." He adds that "Efforts to provide physicians with the knowledge and tools to appropriately prescribe antimicrobial agents in the hospital have existed since the advent of the electronic medical record." Summarizing his fndings, Rice (2018) notes, "Several meta-analyses and systematic review s of antimicrobial s tewardship programs have recently been published. Although their conclusions differed in detail, all found that stewardship programs were effective in reducing the nosocomial occurrence of infections caused by resistant bacteria." He adds, "The understanding of the effectiveness of stewardship interventions has been inhibited by the weaknesses of study designs to date (generally before/ after or quasiexperimental) and the variety of interventions that have been used. Still the preponderance of the evidence suggests that such programs are safe and can have benefcial effects on costs, toxicities, and antimicrobial resistance rates. The salutary effects arise from two different stewardship results: reductions in overall antimicrobial usage and increased heterogeneity of antibiotics used. Of these two results, the more important is to reduce overall antimicrobial usage, thereby decreasing the selective pressure for resistance. Increasing heterogeneity without reducing overall consumption may work in specifc settings, such as outbreaks of ESBL-producing K pneumoniae where cephalosporins are reduced in favor of piperacillin-tazobactam or a carbapenem, but this success often proves a pyrrhic victory because other resistance phenotypes eventually emerge." Septimus (2018) emphasizes that, "It is generally accepted that an appropriate antimicrobial should be started as soon as an infection is identifed in critically ill patients. One of the greatest challenges imposed by infections due to suspected MDROs is how to prescribe broad-spectrum therapy to cover the most likely pathogens and balance effcacy and collateral damage. Antimicrobial stewardship (AS) has been proposed to enable better choices and to reduce unintended consequences, including AR. AS programs have been shown to improve patient outcomes, reduce antimicrobial adverse events, and decrease AR. In 2016, the IDSA and the Society for Healthcare Epidemiologists of America (SHEA) published updated guidelines on implementing an AS program. The guidelines recommend both prospective audit and feedback (AF) and preauthorization because these interventions been shown to improve antibiotic use and are recommended as core components of any stewardship program. AF interventions have also been shown to improve antibiotic use, reduce antibiotic resistance, and reduce CDI rates without a negative impact on patient outcomes." Other approaches include an antibiotic time-out and a day-3 bundle. As Septimus (2018) notes, "Both approaches suggest physicians take time to review the dose, duration, and indication when cultures and new information are available 48 to 72 hours after initiation of empirical therapy." In an antibiotic time - out, clinicians ask themselves: ✦ Do patients have an infection that will respond to antibiotics? ✦ I f so, are patient s on the right antibiotic, dose, and route? ✦ Can a more targeted antibiotic be used to treat the infection (de-escalation)? ✦ How long should patients receive the antibiotic? (Septimus, 2018) Key process measures for the day-3 bundle include: ✦ Was there an antibiotic plan (name, dose, route, interval of administration, and planned duration)? ✦ Was there a review of the diagnosis? ✦ If positive microbiological results were available, was there any adaption of the antibiotic treatment, for example, de-escalation? ✦ If patients were initially started on intravenous (IV) antibiotic therapy, was the possibility of IV-oral switch documented? (Pulcini, et al., 2008) Septimus (2018) adds, "Along with reviewing empirical antibiotics at 48 to 72 hours, IDSA and SHEA also recommend that AS implement guidelines and strategies to reduce antibiotic therapy to the shortest effective duration. Evidence from systematic reviews and randomized controlled trials have demons trated that s tewardship interventions aimed at shorter courses of antibiotic therapy for select clinical syndromes is associated with outcomes similar to those with longer courses in both adults and children with fewer adverse events. Studies support that reduction in exposure of antibiotics can decrease drug resistance, decrease cost, improve adherence, and decrease adverse events." Providers' preferences may be helpful in reducing inappropriate antibiotic prescribing patterns, according to recent research. Physicians are open to receiving information on their antibiotic prescribing patterns, but have specifc preference for receiving that information, according to results from a study published earlier this summer by the Society for Healthcare Epidemiology of America (SHEA). Anticipating physicians' preferences for feedback on antimicrobial use (AU) could help optimize impact of antibiotic stewardship programs and improve the use of antibiotics. "Antimicrobial use feedback is an i m p o r t a n t c o m p o n e n t o f a n t i b i o t i c stewardship initiatives that can improve the use of these drugs," says Tara Lines, PharmD, an infectious disease pharmacy resident at Vanderbilt University Medical Center, and lead author of the study. "Understanding and anticipating the best way to communicate with providers can help drive change by ensuring providers are reached effectively." T he s tud y re p or t s re sp ons e s to a 20 -question survey from 211 inpatient providers at Vanderbilt University Hospital in various specialties. The survey included demographic questions, preferred feedback methods, barriers and comparison metrics, and a hypothetical patient hospitalization scenario assigning provider responsibility for antibiotic use. The clinical scenario became more complex with the number of consulting teams involved in the care of the patient and included transitions of care. Ò Understanding and anticipating the best way to communicate with providers can help drive change by ensuring providers are reached efectively.

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