By Mary Jo Garst, RPh and Marti Heinze, RN, BS
Health care practitioners at many small community hospitals often feel as though they do not have the necessary resources to initiate a traditional antimicrobial stewardship program, and they rarely have dedicated, specially-trained infectious disease (ID) pharmacists and ID physicians on staff. Nevertheless, these hospitals are confronted by the same challenges as large institutions concerning antibiotic misuse. Prudent and appropriate antimicrobial use benefits the hospital, the community, and overall patient outcomes. By developing guidelines that ensure appropriate antibiotic use, limit or reduce overuse, and encourage conversion to oral medications, the hospital can reduce the potential development of multiple drug resistant organisms, reduce harmful side effects, maintain antibiotic efficacy, and reduce costs.
Work Within Your Means
The goal of this project was to develop a program that would help assure the appropriate use of antimicrobials without requiring additional resources or consuming large amounts of time. Our initial interventions were designed using readily available tools and we began by requesting that our lab’s culture and sensitivity (C&S) report print directly to the pharmacy for evaluation. We also asked our lab personnel to provide an in-service on how to accurately interpret the culture results. We began reviewing daily culture results for appropriate and effective antibiotic treatment and to determine whether the patient received the correct dose of the correct medication by the most efficient route. By focusing on minimizing waste (while assuring the minimum number of antibiotics required to effectively treat the infection) and maximizing effects (as compared to the antibiogram and C&S results), we were able to positively influence prescription adjustments for our patients in just minutes per day. Inspired by these results, we looked for other interventions we could implement, still mindful of our minimal resources.
Other Intervention Areas
The following are other steps we took to improve antimicrobial use in our facility:
We worked with the lab to release any updates to the antibiogram to our providers and to post in the physician dictation areas.
We prepared an antibiotic formulary grouping antimicrobials by class and listing available injectable and oral dosage forms. Pharmacists and physicians reviewed the list and compared it to standards, and presented it to the P&T committee with recommendations for possible deletions. After approval, the list was posted in dictation areas to aid providers in ordering available medications and IV to PO options.
A review of specific antibiotic usage coupled with antibiogram sensitivity data from the last several years helped track ordering trends and identify increased bacterial resistance.
Laminated, pocket-sized cards with guidelines for empiric inpatient antibiotic usage were distributed to hospitalists and attending physicians. (For a copy of the card, visit www.pppmag.com/AntibioticCard) Emphasizing an IV to PO program helped reduce the incidence of inherent issues with IV administration of medications, eased conversion from hospital to home administration, and decreased the cost of administration.
Changes Advised and Accepted
From August 2010 through February 2011, the pharmacy reviewed 203 days of C&S data; the average time required per day was 8.2 minutes. A total of 737 finalized inpatient cultures were evaluated, along with numerous gram stain results and partially completed cultures. Interventions or changes were suggested in 7% of the cultures reviewed; of those, 55% were accepted by the providers. Soft cost savings are difficult to capture, but both pharmacists and providers are convinced that the resulting interventions have had a positive effect on patient outcomes and will have long-term benefits for the community.
In the month of April 2011, there were a total of 175 orders for antibiotics, 37 of which were requests for pharmacy to dose—cefepime , levofloxacin , pipracillin/tazobactam , and vancomycin . Pharmacists checked for appropriate renal dosing and advised a reduction in dose for pipracillin/tazobactam twice, with both doses reduced by the providers. Four different patients needed adjustments to their prescribed dosages of levofloxacin and all were accepted and adjusted as recommended by the pharmacist. There were eight suggested changes from levofloxacin IV to oral dosing, and all eight were deemed timely and appropriate. Following these results, we posted a chart outlining suggested outpatient MRSA treatment (CDC, AMA, and IDSA) in the ED physician dictation area. Vancomycin and ceftriaxone use in the ED also has been reviewed with the ED medical director to determine if those products were ordered properly.
The Willingness to Try
Non-traditional antimicrobial stewardship programs can be customized to any size facility and still provide positive outcomes. The key is to begin by developing guidelines and staging small interventions using readily available tools and basic antimicrobial knowledge. Success from these initial steps will provide additional motivation and guidance to continue. The goal of any such program should be to instill appropriate use of effective antibiotics, the reduction of antibiotic resistance, improved patient outcomes, and decreased use of unnecessary and/or ineffective antibiotics. We found the time requirements were less than anticipated and our physicians and staff have been very supportive of this initiative. Our Infection Preventionist presented information on our program and this spark has resulted in an outreach program, started in late April 2011, in which two large hospitals interact with three or four smaller facilities to hone their antimicrobial stewardship programs. As our project has demonstrated, the size of your facility should not the sole determinant of whether patient care can be improved.
Mary Jo Garst, RPh, is a staff pharmacist at Gerald Champion Regional Medical Center (GCRMC) in Alamogordo, New Mexico. She received a BS in pharmacy and an MS in medicinal chemistry from the University of Iowa, and completed a hospital pharmacy residency at Harris Hospital in Fort Worth, Texas.
Marti Heinze, RN, BS, is the Infection Control Practitioner at GCRMC. She received a BS from Friends University in Wichita, Kansas, and will receive a BS in Nursing from Eastern New Mexico University in Portales next year. Marti is also the current President of the New Mexico Chapter of the Professionals for Infection Control.