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Ask the expert: Strategies for setting up a successful antibiotic stewardship program


June 1, 2018

Editor's note: The following is an edited Q&A from the HCPro webcast "How to Establish an Antimicrobial Stewardship Program." Speaker Jennifer Pisano, MD, is medical director of the antimicrobial stewardship program at the University of Chicago Medicine and Biological Sciences.

Q: You said an infectious disease (ID) physician is ideal to lead a stewardship program. But not all community hospitals have an ID specialist available or willing to lead a program. Are there any other types of physicians you feel would be able to fill this role?

Pisano: Finding people with energy and interest in filling this role is probably the most important thing. Hospitalist and intensivists are really nice groups of people if there hasn't already been somebody willing to identify themselves as wanting to be part of the [program].

That can be really helpful if their work is already multi-system. They’re working with lots of consultants, a lot of physicians, with the neurologists, and myriad specialty groups, and they already have relationships with them in place. [That] will help you get a look into how the frontline prescribers are using their antibiotics, what issues they're having, and how to implement change.

Q: What were the strategies you thought were most helpful in getting leadership support for your stewardship program, especially in regard to supporting full-time equivalents (FTE) and budgets?

Pisano: We were lucky to have some key members of our leadership group who were interested in stewardship, and we were able to tap into them and solve the program. But I think just making people aware of what we wanted to do, getting good baseline data, showing some improvement with costs, specifically over the first couple years, was very helpful.

It's hard to argue when you say you're saving a significant amount of money, often in the hundreds of thousands, with a successful restriction program if you need another 50% FTE of a physician or pharmacist. So I'd let the data do the walking and talking and see what's important at your institution. If you can tap into what the institutional focus is at that time, you'll make a big, big impact.

Q: How are you able to maintain a high acceptance rate for stewardship intervention?

Pisano: We've been really lucky about that. I've been at this institution for almost 11 years, and I think that's been helpful. I did a large portion of my training here, so I know many of the physicians already. It's not like a new person asking them to take or follow a recommendation.

We're trying to be very mindful about how interventions are implemented and make sure everyone is on board. We never bring an intervention to the table without knowing that the key players are already on board with it. We do a lot of give and take.

We've done a lot for the surgeons here, which has been a really nice thing because I think in some places that's been difficult. They have their protocols, and it's hard to break in and make big changes. But with data, it can be very helpful. Through collaborations with our infection control [department], we were able to run lists of postop infections and what people were seeing with different surgical subspecialty areas. Then we'd report back to these areas, taking into account what kind of perioperative antibiotics they were using, [then] making some changes and doing another set of data collection once changes were made. Often we saw some decreases in infection.

So, you do a few small projects like that with each group, you build trust with them, and you follow up on the recommendations. Make it clear you think they're important, have data, and care about their patients, and people in general will be very happy and accepting to have your input. Often you'll call up a physician and say, "Hey, you discharged this patient. It doesn't look like the susceptibilities are back yet. You want to change that now?" They're very thankful that you called them to help out with that. It's a give and take, but it's worth it.

Q: You mentioned using Clostridium difficile (C. diff) as an outcome measure. Have you had success with decreasing C. diff rates at your hospital as a result of your stewardship recommendations? And do you have any advice on decreasing C. diff rates?

Pisano: C. diff is a tricky area because it's so multifactorial as to why C. diff rates are high or low at an institution. We were learning more about the community prevalence of carriers of C. diff, people coming in carrying the organism, as well as the reporting of C. diff using positive testing and using different diagnostic testing depending on what microlab it is.

We haven't really focused on C. diff as an outcome measure here as a pilot because we've looked at the rates over time with what our antibiotics are and we didn't see too much of a change, although we are involved in a measure here as a pilot on the use of C. diff screening on selected units. Stewardship has taken control over doing a lot of the education for the pilot. [We're] letting physicians know that just because it's a screen-positive test, that they're not having diarrhea and don't need to be treated. [We're also] trying to follow these people who screen positive as they come in and making sure they're on less C. diff-provoking antibiotics, and you make your recommendations to get people off of proton-pump inhibitors if we can.

That's been a successful measure. It's good to look at [C. diff] and report it, particularly if you're making it a target area. I think we all need to put it on the short list of things that we need to be looking at, since it's such a debilitating infection and has a lot of attention right now.

It's great to be involved in a program that's actually working and a collaborative multidisciplinary project. It's definitely worth crunching the numbers to see if there's a place where you can intervene on. But we haven't had a lot of success at our hospitals on C. diff rates as outcomes from our stewardship program.

Q: What experience or thoughts do you have for computer-based decision support tools for stewardship, such as TheraDoc, MedMine, Epic, etc.?

Pisano: This is another area where we've been bouncing questions off each other, seeing what works and what doesn't work. And there's a lot of information out there.

I know a lot of institutions use TheraDoc—we don't here—and love it and incorporate it with their other tools in the electronic health record. Some still use MedMine—we still do here—and that's been a nice platform. It lets us look at where we're seeing certain infections and organisms, and what the susceptibilities are. It's a pretty user-friendly interface that you can manipulate yourself, and you're not at the mercy of someone else to pull the data [for you].

We're one of the first sites in the country with Epic. We've got the infection control module and we have the stewardship module. We're trying to incorporate the use of that as part of the medical record. So I think that's "to be continued." If people want to contact me in six months to a year to see how things are going, I'd be happy to chat. Right now, I think it's really good. We get alerts on time, it's a user-friendly interface, and you're not at the mercy of other people to pull data for you. But we are working on making it more interactive.

Q: You mentioned in the presentation about family members asking about whether certain antibiotics are appropriate. Have you had much feedback from patients in terms of being concerned about what types or what amounts of antibiotics they're receiving?

Pisano: Absolutely, and I think it's awesome to see the change happen over the last five years. I feel like it was much more prevalent in the past for patients to come in and almost demand an antibiotic, particularly outpatients for sinusitis or a respiratory viral infection or a sore throat because that's what's worked for them [before]. Of course you never know if it's because the antibiotic is working or if the viral illness, if that's what they have, is getting better at the same time as they're starting the antibiotics.

I've had really nice conversations with patients around the use of antibiotics. They'll bring up, "Should I take a probiotic with this?" or, "Will this kill all my good bacteria?" or, "I was reading about C. diff in The New York Times and have questions about if this is really necessary."

I find that if you're not going to give patients an antibiotic, especially in an outpatient setting where I don't think we have the stewardship oversight built in, they want to make sure that you'll be there in five days if they're still having symptoms and not getting better. So, one of the strategies I use is to give them my information and say, "Hey, if you still feel bad in five days, I'll call that prescription in for you, no problem." I've probably had one person in the last five years call me in five days and say, "Hey, I think I need the antibiotic." Gave it to them, they did better, fine. No harm, no foul.

Of course you need to gauge who the patient is, what's going on, what's going to happen to them if you don't treat them and they do have a bacterial infection. But the Centers for Disease Control and Prevention has some really nice educational resources for patients centered around their Get Smart Week.

I think it's been really exciting to talk to patients about, "Is this antibiotic really necessary?" People get it. They're smart. All it takes is knowing one person who's gotten C. diff and you'll always question if you need an antibiotic in the future.

Q: What do you think of the increased media coverage on antibiotic resistance?

Pisano: Stories are powerful. People don't need to see the data or the trend lines. Of course it's out there if you want to show it to them, but you read one or two stories and attach faces to the stories, and that sticks with people.

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