Antibiotic stewardship the old-fashioned way

Hospital assessment is key.


Where: Mercy Health Saint Mary's, a 344-bed acute care hospital in Grand Rapids, Mich.

The issue: Reducing inappropriate antimicrobial use in a community hospital.

Background

When Lisa Dumkow, PharmD, an infectious disease-trained pharmacist, was hired by Saint Mary's in 2013 as the clinical pharmacist in charge of antimicrobial stewardship, she had a question. “The first thing that I asked was, “Do we have the budget to get clinical decision support [software]?” said Dr. Dumkow during a session at IDWeek 2014, held in Philadelphia last October.

Decision support software has helped other hospitals improve antibiotic stewardship by encouraging optimal prescribing and appropriate de-escalation, Dr. Dumkow said. But it's expensive, at about $100,000 to purchase with additional ongoing costs. That was more than Saint Mary's was prepared to spend. “Unfortunately, for most community hospitals, the answer is no, we don't have the budget to get clinical decision support software,” she said.

The lack of technology was a setback, but not an impossible one. “Our hospital actually implemented our stewardship program without this software,” said Dr. Dumkow.

How it works

Dr. Dumkow started her stewardship program by assessing the needs of her hospital, going on rounds and interviewing clinicians. “What everybody was really clamoring for was education,” she said, describing a patient she saw on her first rounds with a urinary tract infection that was pan-susceptible. “I said, ‘Why is that patient still on ertapenem?’…The ICU attending said, ‘We never de-escalate. We never change antibiotics.’”

In addition to failure to de-escalate, she found that unnecessary double coverage for gram-negative organisms was common. “We were using a lot of beta-lactams plus fluoroquinolones,” said Dr. Dumkow.

The overuse was caused by a number of factors, including outdated protocols and a lack of localized guidance. “The sepsis advisor in [our electronic health record] is actually where most of our doctors were getting their recommendations for antimicrobial therapy and had not been updated for several years,” said Dr. Dumkow. Additional pharmacy policies were also outdated which made renal adjustment and switches from IV to oral formulations difficult.

She worked with her team of infectious disease physicians and hospital experts to update protocols and guidelines then took the new advice and the evidence to support it out to the front lines. “We were kind of the stewardship pilgrims, bringing this message to everyone about what our antibiogram currently looks like and how we should change prescribing,” Dr. Dumkow said. “Our own data speak louder than any words. Our critical care physicians and hospitalists were really on board with this and said, ‘What should we be doing instead?’”

To help them answer that question in daily practice, an intranet site with stewardship guidance was created. In addition, Dr. Dumkow along with her students and residents review all antibiotic prescriptions around the hospital every day. “We just call pharmacists and providers working on that floor with interventions throughout the day,” she said.

Results

In the first 6 months, from October 2013 to March 2014, Dr. Dumkow's team made 1,575 recommendations to change prescribing, and 91% of them were accepted. “About half of them were de-escalation or discontinuation of therapies. I did a PO switch in 17%, a dose optimization in 14%,” she said. More than a third of the suggestions were made through other pharmacists working with their specific patient care team who were not specifically trained in infectious disease, she noted.

As one might expect, the hospital's prescription patterns changed during that time, too, to use less broad-spectrum drugs. “We had significant decreases in carbapenem usage—meropenem, ertapenem. Also, for the fluoroquinolones, specifically levofloxacin, we decreased our utilization by approximately half,” said Dr. Dumkow.

Clostridium difficile infections also decreased. “Our rate prior to antimicrobial stewardship was 17 cases per 10,000 patient-days. Our rate post was 11.4. In June of [2014], we actually only had 1 case, so our rate was only 1.3 for 10,000 patient-days,” said Dr. Dumkow.

Next steps

The stewardship program also reduced costs, saving over $200,000 in its first year of operation. That was enough money to get Dr. Dumkow the stewardship tool that she wanted from the start. “We actually just got approved for clinical decision support software,” she said. The program may also get some allocated time from an infectious disease physician.

Words of wisdom

This project proves, however, that stewardship is possible, even without dedicated time from infectious disease specialists or expensive computer systems, Dr. Dumkow concluded. With training and authority, all hospital pharmacists can play a key role in improving inpatient antibiotic prescribing.

“These pharmacists are often familiar with the hospital formulary and antibiogram,” she said. “They can alert you to missteps that are being taken with antimicrobial prescribing at the time, instead of retrospectively having to go back and look at those patients.”