March 29, 2011
Hospital antimicrobial stewardship programs (ASPs) have expanded in scope over the past several decades in part a response to the continued rise in antibiotic resistance and the knowledge that this resistance is driven by antibiotic use. In human medicine, a major factor contributing to antibiotic misuse is inappropriate clinician prescribing (compounded by patient demand). Stewardship programs seek to temper misuse in hospital settings, utilizing a variety of strategies to optimize clinical outcomes while minimizing unintended consequences of antimicrobial use, including toxicity, the selection of pathogenic organisms (such as Clostridium difficile), and the emergence of resistance.
A new study in Infection Control and Hospital Epidemiology, funded by the CDC and CDDEP’s Extending the Cure project, takes stock of ASPs in the United States, examining how they have evolved over the past decade in terms of both quantity and characteristics asking what proportion of hospitals in the United States currently implement or are planning ASPs, and of those who do, what the programs look like in terms of core elements and personnel.
Based on results of a survey administered to IDSA Emerging Infections Network members, the study reports the promising finding that stewardship programs are on the rise. Seventy-three percent of respondents reported an ASP already in place or one in planning stages, in comparison to 50% who reported planned or existing ASPs ten years ago.
In addition to suggesting growth in number of stewardship programs, the survey results also reflect changes in program strategies over time. Stewardship is a tricky concept to pin down, and over the years a wide range of strategies have been utilized to influence antibiotic prescribing patterns in hospitals. In 2007, SHEA and IDSA issued a set of guidelines for developing ASPs in institutional settings, culling together existing research to offer recommendations on effective tactics. Primary strategies include formulary restrictions, post-prescription review, and physician feedback. Examples of secondary ASP strategies include providing education, issuing guidelines, and drafting protocol for transitioning from parenteral to oral therapy.
While formulary restrictions, including pre-authorization requirements, have historically served as the most common primary strategy for ASPs, this study finds that requiring pre-authorization is a significantly less common element among planned ASPs than among existing programs. Instead, newer programs are moving more towards tailored, contextualized strategies that make use of post-prescription review and physician feedback. Perhaps this shift is a result of recent research suggesting the value of adapting ASPs to local context in terms of needs and resources.
The study authors also examined barriers to implementing stewardship programs, and unsurprisingly, the largest barriers remain cost and personnel resources, especially in small (<200 beds) and community hospital settings. The study authors note that while the overarching goal of antimicrobial stewardship is optimizing treatment outcomes, an unstated goal is cost savings. Additionally, although the SHEA/IDSA guidelines recommend directly compensating infectious disease specialists for antimicrobial stewardship work, 52% of respondents reported that ID physicians received no direct compensation for their works with ASPs.
Moving forward, more data is needed to support the expansion of ASPs, especially in smaller community hospitals. Calling such hospitals the new frontier of ASP development, the study points to the need for data particularly cost data to influence community hospital administrators to invest in ASPs. Interestingly, the survey results suggests that data could also be playing a more powerful role in influencing prescriber behavior, as surveyed physicians believe that their colleagues lack of knowledge is a primary reason for antimicrobial misuse. This finding supports the idea that clinician education is and should be a fruitful element of stewardship programs.
The study is a reminder that while we are making progress in establishing antibiotic stewardship as a priority in hospital settings, there are contexts where we have a ways to go. One of the challenges moving forward will be to continue to refine the concept of stewardship itself in order to further address the tension in establishing strategies that can be both effective across hospital contexts and tailored to local needs.
Image credit: Flickr: The Doctr
