1. Antibiotic Stewardship Program (ASP) Development
Acute Care

2. Presenter— Sara Cosgrove
Sara Cosgrove, MD, MS
Title: Professor of Medicine, Division of Infectious Diseases, Director, Antimicrobial Stewardship Program, Associate Hospital Epidemiologist
Place of work: Johns Hopkins School of Medicine
Program address:

3. Housekeeping Keep phone on mute
Use ‘chat’ feature in WebEx if you need to speak
Hold off most questions until the end during Q&A
Participate when asked

4. Objectives By the end of this module, participants will be able to—
Understand the key personnel involved in developing an Antibiotic Stewardship Program (ASP)
Understand how to work with a senior executive to further program goals
Discuss the pros and cons of common ASP interventions
Discuss evaluation metrics for ASPs
Understand the steps involved in establishing an ASP

5. Key Personnel and Essential Relationships

6. Essential Team Members
Role
Qualification
Physician
Physician leadership critical as most interactions are with medical staff
Determining program goals
Settling differences of opinion between other AS members and prescribers
Bridge to executive leadership
Ideally trained in infectious diseases
Interest in antibiotic use and patient safety
Diplomatic and collegial
Pharmacist
Interventions
Coordination of data needs
Bridge to department of pharmacy
Same as for physician
Comfortable advising physicians and other providers

7. Groups and Departments
Antibiotic Stewardship Program
Medical Staff
Information Technology Department
Senior Executive Leadership
Pharmacy
Microbiology
Department of Nursing
Infectious Diseases Physicians
Infection Control Department
Regulatory Affairs
Patient Safety Department
Quality Improvement Department
P&T Committee 17

8. Essential Relationships: The Role of the Senior Executive in ASPs
Member
Role
Senior executive
Assists ASP with aligning programs goals with the organization’s strategic goals
Identifies financial resources for the ASP and its activities
Connects ASP to stakeholders across the institution
Ensures the ASP leadership is included in high-level meetings
Assists with reducing barriers to progress
“Outlier” clinician prescribing practices

9. Engaging Senior Executives
Invite to join the hospital AS Committee
Invite to periodically attend unit CUSP meetings
Provide regular executive summaries of work being performed
Show appreciation for resources provided

10. Essential Relationships
Member
Role
Department of Pharmacy
Enforces prescribing policies
Generates data on antibiotic use
Identifies prescribing trends
Assists with some AS interventions (non-stewardship pharmacists)
IV to oral conversion protocols
Therapeutic antibiotic monitoring protocols
Pharmacy and Therapeutics (P&T) Committee
Decisions regarding formulary and restriction status of antibiotics
Endorsement of guidelines and restriction policies
Some AS programs/committees report to P&T

11. Essential Relationships
Member
Role
Medical Staff
Source of clinical champions
Collaborators in development of guidelines and policies
Management of outlier prescribers
Other Infection Diseases Physicians
Endorse guidelines in their practice
Perform consults for patients with complicated infectious disease problems or for patients receiving certain antibiotics
Their buy-in is important to prevent undermining program!

12. Essential Relationships
Member
Role
Information Technology
Assist with collating antibiotic, microbiology and clinical data to facilitate identification of cases for intervention
Provide antibiotic use data for the institution and for reporting to the CDC NHSN AUR module
Ensure ASP involvement in relevant decisions regarding EHRs and other software
Microbiology Laboratory
Practical interpretation of microbiology data
Antibiogram development
Selective reporting of susceptibility testing
Selection and implementation of rapid diagnostic tests

13. Essential Relationships
Member
Role
Infection Control Department
Knowledge of trends regarding resistant organisms, Clostridium difficile, and clinician behaviors in the institution
Familiarity with acquiring, tabulating, and disseminating data
Department of Nursing
Education of nurses regarding their role in antibiotic stewardship
Indication and duration of antibiotic therapy
Adverse event detection
Appropriate microbiology specimen collection
Timing of therapeutic drug level acquisition

14. Essential Relationships
Member
Role
Regulatory Affairs
Collaboration to ensure compliance with The Joint Commission Standard and other regulations
Quality Improvement Department
Collaboration to ensure optimal compliance with quality metrics while ensuring rational antibiotic use (e.g., Sepsis Core Measure)
Patient Safety Department
Resources for interventions to improve antibiotic use or laboratory testing

15. Establishing an AS Committee
Membership
ASP members
Senior executive
Medical staff representing different departments
Nursing representative
Pharmacy representatives
Meetings
Monthly or quarterly
Minutes
Take and distribute

16. Establishing an AS Committee: Activities
Evaluate
Antibiotic use data
CDI rates
Antibiogram changes over time
Recommend areas for improvement interventions
Review
Guidelines and practices developed to optimize antibiotic prescribing in the facility
Materials for patient and healthcare worker education regarding optimal antibiotic prescribing
ASP responses to antibiotic shortages
Assure ASP and its procedures and policies meet relevant regulations and guidelines
Review approaches for reporting culture and susceptibility data

17. Development of Institutional Guidelines for Antibiotic Use
Why are guidelines important?
Evidenced-based and standardized recommendations based on local data
Adherence to the use of formulary drugs
Intellectual back-up for ASP
Available at the point of care
Engagement of thought leaders in their development

18. Approach to Development of Guidelines
Select common conditions that contribute significantly to antibiotic prescribing in your institution
Community-acquired pneumonia
Urinary tract infections/asymptomatic bacteriuria,
Healthcare-associated pneumonia/ventilator-associated pneumonia
Skin and soft tissue infections
Intra-abdominal infections
Provide recommendations for interpretations of rapid diagnostic tests
Prioritize syndrome-based over antibiotic-based guidelines
Consider guidelines for select antibiotics
Those that are expensive, highly toxic, and/or used for specific indications

19. Approach to Development of Guidelines
Identify collaborators who are subject matter experts
Review national guidelines and guidelines from other institutions
Use the Four Moments of Antibiotic Decision-Making approach
Diagnostic criteria for infection
Appropriate cultures and empiric therapy
Diagnosis including relevant cultures,
Narrowing and IV to oral conversion
Duration
Be succinct!
Determine how to get guidelines to the point of care
Electronic, handbook, pocket card, available in EHR

20. Options for Interventions
Approach
Definition
Pros
Cons
Pre-prescription approval of antibiotics
Phone call placed or form filled out before pharmacy dispenses antibiotic
Reduces initiating unnecessary antibiotics
Optimizes empiric antibiotic choices
Opportunity to advise about sending appropriate cultures
Impacts use of restricted agents only
Addresses empiric use more than downstream use
Real time resource intensive
Post- prescription review and feedback of antibiotics
Downstream review of appropriateness of antibiotic therapy, usually at hours
More clinical data available to enhance uptake of recommendations
Greater flexibility in timing of interventions
Can address duration of therapy
Recommended action generally optional and may not be followed
Syndrome-specific stewardship interventions
Stewardship “bundle” about a specific disease process
(e.g., CAP)
Addresses empiric and downstream therapy
More engaging for clinicians
Opportunity for sustained learning
Must have a method to identify cases

21. Specific Examples of Interventions
Use of a costly or salvage drug
(e.g., daptomycin, meropenem, ceftolozane/tazobactam)
IV to PO conversion
Approach
Pro
Con
Prior approval or post-prescription review and feedback
Easy to identify cases
Does not address the majority of antibiotic use in hospitals
Approach
Pro
Con
IV to PO conversion of the same agent (easier); IV to PO conversion of different agents (more difficult)
Easy to identify opportunities if same agent; can involve staff pharmacists; can reduce length of stay and need for IV access
Impacts a limited number of agents if converting same agents only

22. Specific Examples of Interventions
Implementation of an antibiotic time out (self-stewardship)
Implementation of rapid diagnostic testing
Approach
Pro
Con
Providers or teams of clinicians review their patient’s receiving antibiotics to determine if the antibiotics are truly needed or if they could be modified.
Engages frontline clinicians/teams to think about optimizing prescribing
Can be challenging to implement; sometimes clinicians don’t know what they don’t know
Approach
Pro
Con
Call prescribers with results of rapid tests to assist with optimal antibiotic choice
Often seen as more of an “educational” interaction
May impact limited numbers of patients, need to ensure test is highly accurate for prescriber “buy-in”

23. Metrics

24. What to Measure and Report
Know your audience.
Clinicians want to know their patients won’t be harmed.
Administrators want to see cost-savings.
Measure
Number and type of interventions performed
Results of a specific initiative
Improvement in peri-operative antibiotic use
Improvement in not treating asymptomatic bacteriuria
Reduction in daptomycin use and associated cost after an intervention

25. What to Measure and Report
Decrease in (or stable) use of antibiotics over time
Evaluate quarterly
Stratified by unit or service and agent (or group of agents)
Normalize antibiotic use data (e.g. per 1000 patient-days present)
Allow targeting of areas with high or increased use
If infrastructure available use CDC NHSN AU definitions and methodology
Attach costs to the antibiotic use
Patient outcomes
Clostridium difficile infection rates
Length of hospital stay

26. How Do I Get Started?

27. Change According to John Kotter
Institutional change from the business perspective
8-step model to facilitate change in an institution
Morris AM et al. Healthcare Quarterly. 2010;13:64-70.

28. Leading Change Steps Step 1: Create a sense of urgency
Focus on patient safety, regulatory requirements, and drug costs with hospital leaders
“Our CDI rates are too high and we are hurting patients”
“We are not compliant with The Joint Commission Antimicrobial Stewardship Standard and run the risk of a citation at our next visit”
Step 2: Form a powerful guiding coalition
Team of leaders who represent key stakeholders
Team member characteristics: position power, expertise, credibility, leadership

29. Leading Change Steps Step 3: Create a compelling vision for change
Vision statement “Helping patients receive the right antibiotics when they need them”
Step 4: Communicate the vision effectively
Communicate to all levels (senior leadership/boards; department heads/unit directors; physicians/prescribers)
Communicate regularly
Develop an elevator speech
Step 5: Empower others to act on the vision
Work with teams to develop mutually acceptable approaches (compromise)
Empower non-traditional decision-makers
Non-ASP Pharmacists
Nurses

30. Leading Change Steps Step 6: Plan for and create short term wins
Begin with low hanging fruit
Asymptomatic bacteruria
Durations of therapy
Feed back the data
Recognize the team and the frontline staff as critical in making the changes

31. Leading Change Steps
Step 7: Consolidate improvements and create still more change
Step 8: Institutionalize new approaches
Ensure the understanding of the positive results
Strive for prescribers to be stewards of antibiotics
One of the primary goals of this project is to assist ASPs in working with frontline teams to permanently change how they think about antibiotic prescribing.

32. Program Website Access

33. Questions THANK YOU FOR PARTICIPATING!
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THANK YOU FOR PARTICIPATING!

34. Next Steps Antibiotic Stewardship Program Development
Improving Antibiotic Use Is a Patient Safety Issue
Questions?