According to the CDC, about 30 percent of antibiotics prescribed in United States hospitals are “unnecessary or suboptimal.”
Thus, individual physicians must improve their prescribing practices to protect patients from avoidable side effects, as well as to more effectively treat infections, says George E. Nelson, M.D., director of the Vanderbilt Antimicrobial Stewardship Program. Yet, it will require antimicrobial stewardship on a global scale to effectively combat resistance, he added.
Nelson is part of a larger team at Vanderbilt University Medical Center and Monroe Carell Jr. Children’s Hospital at Vanderbilt working tirelessly to monitor antimicrobial use and develop treatment guidelines within the hospitals. Both institutions were recently designated by the Infectious Diseases Society of America (IDSA) as Antimicrobial Stewardship Centers of Excellence.
“This is very welcomed recognition, and it reflects a tremendous amount of work that our stewardship team has accomplished,” Nelson said.
Hard-earned Designation
Only 145 hospital programs have ever received the IDSA Center of Excellence designation, which is grounded in core elements of antimicrobial stewardship set forth by the CDC.
Core elements include granular monitoring of antimicrobial use, plus prospective interventions centered around specific pathogens, such as pharmacy protocol, facilities, specialties or staff makeup. Stewardship teams report their findings to all parties, including hospital leadership and the IDSA, to inform and educate.
For their part, the IDSA regularly serves as a policy advocate and offers myriad professional development opportunities related to proper use of antimicrobials. The organization also sponsors basic and clinical research to further this mission.
“We salute the IDSA for their efforts to promote awareness of antimicrobial stewardship and the measures health care organizations can take to optimize use of antimicrobial drugs,” Nelson said.
Beyond the core elements, Centers of Excellence must also conform with practice guidelines from the IDSA and from the Society for Healthcare Epidemiology of America.
Site-specific Efforts
At Vanderbilt, Nelson and his colleagues are addressing antimicrobial stewardship on several fronts.
The team uses electronic health records to monitor antimicrobial use patterns and clinical laboratory results in the hospitals every day. When issues arise, they may reach out directly to clinicians to discuss prescription adjustments, such as shorter courses. This approach promotes open dialogue that can improve a prescription provider’s decision-making for future patients, Nelson said.
At the pharmacy level, the team oversees the Vanderbilt drug formulary and has worked closely with the Pharmacy and Therapeutics Committee to establish a list of 25 antimicrobials – primarily newer broad-spectrum or “last-resort” options – that require approval from an infectious diseases specialist to dispense.
“We’re here to optimize therapy, hopefully with the major benefits of reducing drug resistance and improving outcomes through multidisciplinary collaborative programs and a focus on individual patient care,” Nelson said.
Evidence-based Stewardship
Since launching in 2009, the Vanderbilt Antimicrobial Stewardship Program has proven its worth.
Nelson and colleagues have, for example, reduced the number of outdated penicillin allergy labels on patient charts. This helps expand the antibiotic arsenal available for treatment and is backed by research that suggests more than half of patients with a penicillin allergy chart notation are actually at low risk of having an adverse reaction.
The team also has developed a successful framework and implementation strategy to support interventions related to antimicrobial use. As a proof of concept, implementing the approach reduced concomitant vancomycin and piperacillin-tazobactam use from 4.2 to 0.7 percent among inpatients at Vanderbilt. This effort complements existing risk models at Vanderbilt and Children’s Hospital designed to combat antibiotic overuse.
Other efforts include focusing on antimicrobial use at hospital discharge and in outpatient clinics – care transitions where best practices can sometimes slip through the cracks. Now, Vanderbilt outpatient clinics are also included in oversight provided by Nelson’s team.
A major goal of the work is to reduce costs related to prevention and treatment of infectious diseases. Current estimates place the cost to manage just six of the most drug-resistant pathogens in the United States at $4.6 billion annually. The IDSA estimates that resistant infections will cost the global economy an estimated $100 trillion by 2050.
