How antimicrobial stewardship teams cut antibiotic use in North Carolina

North Carolina hospitals test protocols for decreasing antibiotic-resistant strains. (Getty/sudok1)

There are plenty of best practices for combating the overuse of antibiotics in hospitals, but most institutions are unaware of the recommendations or are not implementing them.

A recent study found that when two particular recommendations from the Infectious Diseases Society of America were implemented in four North Carolina community hospitals, they were able to make a meaningful reduction in the use of antibiotics.

The study, out of Duke University and published in JAMA Network, examined two core recommended antibiotic stewardship strategies—preauthorization (PA) and postprescription audit and review (PPR)—to see whether these protocols are feasible for community hospitals. Researchers implemented the test in four community hospitals in North Carolina and looked at patients receiving targeted antibacterial agents or alternative non-study antibacterial agents between October 2014 and October 2015.

The study found that a PPR and a modified PA strategy were feasible, but a strict PA was not feasible. The PPR was most successful in that it decreased antimicrobial use and encouraged more direct interactions with clinicians than the modified PA strategy.

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How it worked

As hospitals continue to observe increasing rates of drug-resistant pathogens—which can lead to morbidity, mortality and hospital costs—hospital improvement programs involving antimicrobial stewardship (AS) teams are essential to curbing these trends.

Most of the studies up until this point have been performed in large, private hospitals in contrast to the small, community hospitals that are common around the U.S. And these hospitals typically have limited or no resources or trained staff dedicated to AS, yet have the highest rate of antibiotic use. The hospitals used in this trial were enrolled in the Duke Antimicrobial Stewardship Outreach Network via the Duke University Health System and had not yet undergone prior stewardship training.

“The biggest challenge for pharmacists was the issue of competing priorities. That is, all the participating pharmacists still had to fulfill non-stewardship duties and responsibilities,” Deverick Anderson, M.D., of the Duke Center for Antimicrobial Stewardship and Infection Prevention's Division of Infectious Diseases at Duke University School of Medicine, told FierceHealthcare. “I think this issue played out in the high number of ‘missed opportunities’ that we observed during the study.”

The formulas used at the hospitals included a modified PA, in which the prescriber had to receive pharmacist approval for continued use of the antibiotic after the first dose, and PPR, in which the pharmacist would engage the prescriber about antibiotic appropriateness after 72 hours of therapy. Two hospitals performed modified PA for six months, then PPR for six months. The other two hospitals performed the reverse.

One or more pharmacists at each site received standardized training by study personnel to address common questions and anticipated arguments and to establish an enhanced knowledge base regarding the targeted antimicrobials.

Results show pharmacists felt more comfortable discussing antibiotic-related issues after training but had mixed feelings that their recommendations improved patient care. And adding stewardship interventions to current workloads represented a burden to pharmacist workflow.

RELATED: Study: 1 in 4 antibiotic prescriptions likely inappropriate

Overall, antibiotic use decreased during PPR compared with control groups, but not during modified PA.

Almost 90% (74 of 84) of clinicians in the study hospitals who responded to the survey agreed that AS was important for patients; more than 55% (48 of 83) agreed that pharmacist antibiotic recommendations could improve the care of their patients.

Researchers suggest that community hospitals may benefit from providing dedicated resources (time and personnel) that can perform stewardship interventions at all times and offer sustainability for the program, rather than pulling from current resources. In addition, rapid diagnostics and electronic health record data review tools could help streamline PPR and other stewardship activities, although many community hospitals do not have these resources in place.

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“Now that we know which of the core stewardship interventions is most feasible in community hospitals (post-prescription review), I think it would be good to understand how well the intervention works in this setting,” Anderson said. “The intervention is ‘evidence-based,’ but most of that evidence was gathered in large, academic centers."

Anderson added that he believes the intervention will also work in community hospitals. “But I think there’s still a lot more to learn about how well it works and if it can be made even more effective with higher resources.”