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The Search for Good Antimicrobial Stewardship
JOURNAL
ON
QUALITY IMPROVEMENT
The issue of antimicrobial resistance is replacing increasing costs as the primary driver for improved use of antimicrobials EDITORIAL
The Search for Good Antimicrobial Stewardship DALE N. GERDING, MD
A
ntimicrobials (which include all anti-infectives, including antibiotics) are among the most valuable therapeutic agents in the armamentarium of the health care provider. Antimicrobial resistance among microorganisms occurs as a result of both appropriate and inappropriate use of antimicrobials. Because of resistance issues, antimicrobial use affects not only the patient to whom it is prescribed but also all patients sharing the environment now and in the future. Since antimicrobial use is linked to the development of antimicrobial resistance—and surveys of antimicrobial use have deemed as much as 50% of use to be inappropriate—one approach to the resistance problem has been to “improve” the use of antimicrobials. Targeted at the portion of use that is inappropriate, this approach generally aims to reduce overall antimicrobial use, with the assumption that this reduction in use will result in a reduction or prevention of resistance. Reduction in use is a process goal, whereas the reduction of antimicrobial resistance is an outcome goal. There may be (and almost certainly is) inherent benefit in improved antimicrobial use (better clinical Dale N. Gerding, MD, is Chief, Medical Service, VA Chicago-Lakeside Division, and Professor and Associate Chair, Department of Medicine, Northwestern University, Chicago. Pleased address correspondence to Dale N. Gerding, MD, Chief, Medical Service, VA Chicago-Lakeside Division, 333 E Huron St, Chicago, IL 60611; phone 312/469-2193; fax 312/469-2313; e-mail [email protected]. Copyright © 2001 by the Joint Commission on Accreditation of Healthcare Organizations
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outcomes, less toxicity, lower cost) independent of the issue of resistance, but the current driver for improved use is the increase in antimicrobial resistance. In the past (and, in many institutions, present) the major driver for antimicrobial use change has been increasing cost, which has placed many prescribers on the defensive, for they feel that the best antimicrobials for their patients are being denied because of cost. The insights that Schiff and colleagues draw from their experience in the Institute for Healthcare Improvement’s national collaborative Improving Inpatient Antibiotic Prescribing1 make it clear that changing the use of antimicrobials is not an easy process. In the view of the Society for Healthcare Epidemiology of America and the Infectious Diseases Society of America, what Schiff and colleagues are seeking is the achievement of good antimicrobial stewardship.2 This does not mean denying use of antimicrobials. After all, they are not cigarettes or cocaine: They are highly valuable life-saving therapeutic agents that have been designed to benefit mankind by being used. Good antimicrobial stewardship is the optimal selection, dose, and duration of an antimicrobial that results in the best clinical outcome for the treatment or prevention of infection, with minimal toxicity to the patient and minimal impact on subsequent resistance. Good antimicrobial stewardship is akin to motherhood and apple pie. Schiff and colleagues have struggled with the practical implications of achieving good stewardship, and we can all benefit from their insights gained during several years of working to improve antimicrobial prescribing.
8
Copyright 2001 Joint Commission on Accreditation of Healthcare Organizations
403
THE JOINT COMMISSION It is important to note that the authors do not claim to have all the answers but do describe the many pitfalls they have encountered in their efforts. At this time it is not clear to me what approach is ultimately best for increasing good stewardship. There may be no single answer to achieving good stewardship, but Schiff et al suggest that electronic computer ordering—so-called order entry—may be the ultimate answer. We use order entry in our hospital to reduce medication errors, and it is very successful, but even with order entry it is still possible to “perfectly order the wrong antibiotic” for a patient. That is, the dose, duration, drug compatibility, allergy compatibility, and adjustment for renal failure may all be done without error, but the choice of the antibiotic may be completely inappropriate. Preventing this occurrence will require development of computerized databases and software programming of a highly sophisticated level of quality that will incorporate all the best information from guidelines, hospital antibiograms, patientspecific microbiology cultures and susceptibility, the hospital formulary, and complete patient-specific laboratory and pharmacy data. Only a select few hospitals in the United States have this level of antibiotic decision support sophistication, and it will be many years before those systems can be deployed widely. In addition to good antimicrobial stewardship, there are other ways to reduce antimicrobial resistance. Although Schiff and colleagues do not discuss it, a highly effective method to control use of specific antimicrobials lies in removing them from the formu-
404
lary entirely or placing them in a restricted access status, limited to specific specialists. This draconian approach has been the most effective method to rapidly change antimicrobial use. Infection control committees I have sat on have employed these strategies for gentamicin and clindamycin and shown dramatic reductions in infections caused by specific organisms resistant to these drugs. Finally, as Schiff et al acknowledge, altering antimicrobial use might not address all antimicrobial resistance. Good infection control is absolutely critical to the prevention of horizontal spread of resistant organisms in the inpatient environment. After all, if every patient infected with MRSA (methicillinresistant Staphylococcus aureus) or VRE (vancomycinresistant Enterococcus) were to be prevented by rigorous infection control practices from transmitting the organism to another patient, we would readily eliminate most of these resistant organisms from our institutions. So until that computerized antimicrobial decision support system comes to your hospital, safeguard those antibiotics by practicing good antimicrobial stewardship, and don’t forget to wear gloves and wash your hands. J References 1. Schiff GD, et al: Improving inpatient antibiotic prescribing: Insights from participation in a national collaborative. Jt Comm J Qual Improv 27:387–402, 2001. 2. Shlaes DM, et al: Society for Healthcare Epidemiology of Amer-
ica and Infectious Diseases Society of America Joint Committee on the Prevention of Antimicrobial Resistance: Guidelines for the Prevention of Antimicrobial Resistance in Hospitals. Infect Control Hosp Epidemiol 8:275–291, 1997.
AUGUST 2001 JOURNAL Copyright 2001 Joint Commission on Accreditation of Healthcare Organizations
ON
QUALITY IMPROVEMENT
The issue of antimicrobial resistance is replacing increasing costs as the primary driver for improved use of antimicrobials EDITORIAL
The Search for Good Antimicrobial Stewardship DALE N. GERDING, MD
A
ntimicrobials (which include all anti-infectives, including antibiotics) are among the most valuable therapeutic agents in the armamentarium of the health care provider. Antimicrobial resistance among microorganisms occurs as a result of both appropriate and inappropriate use of antimicrobials. Because of resistance issues, antimicrobial use affects not only the patient to whom it is prescribed but also all patients sharing the environment now and in the future. Since antimicrobial use is linked to the development of antimicrobial resistance—and surveys of antimicrobial use have deemed as much as 50% of use to be inappropriate—one approach to the resistance problem has been to “improve” the use of antimicrobials. Targeted at the portion of use that is inappropriate, this approach generally aims to reduce overall antimicrobial use, with the assumption that this reduction in use will result in a reduction or prevention of resistance. Reduction in use is a process goal, whereas the reduction of antimicrobial resistance is an outcome goal. There may be (and almost certainly is) inherent benefit in improved antimicrobial use (better clinical Dale N. Gerding, MD, is Chief, Medical Service, VA Chicago-Lakeside Division, and Professor and Associate Chair, Department of Medicine, Northwestern University, Chicago. Pleased address correspondence to Dale N. Gerding, MD, Chief, Medical Service, VA Chicago-Lakeside Division, 333 E Huron St, Chicago, IL 60611; phone 312/469-2193; fax 312/469-2313; e-mail [email protected]. Copyright © 2001 by the Joint Commission on Accreditation of Healthcare Organizations
VOLUME
27
NUMBER
outcomes, less toxicity, lower cost) independent of the issue of resistance, but the current driver for improved use is the increase in antimicrobial resistance. In the past (and, in many institutions, present) the major driver for antimicrobial use change has been increasing cost, which has placed many prescribers on the defensive, for they feel that the best antimicrobials for their patients are being denied because of cost. The insights that Schiff and colleagues draw from their experience in the Institute for Healthcare Improvement’s national collaborative Improving Inpatient Antibiotic Prescribing1 make it clear that changing the use of antimicrobials is not an easy process. In the view of the Society for Healthcare Epidemiology of America and the Infectious Diseases Society of America, what Schiff and colleagues are seeking is the achievement of good antimicrobial stewardship.2 This does not mean denying use of antimicrobials. After all, they are not cigarettes or cocaine: They are highly valuable life-saving therapeutic agents that have been designed to benefit mankind by being used. Good antimicrobial stewardship is the optimal selection, dose, and duration of an antimicrobial that results in the best clinical outcome for the treatment or prevention of infection, with minimal toxicity to the patient and minimal impact on subsequent resistance. Good antimicrobial stewardship is akin to motherhood and apple pie. Schiff and colleagues have struggled with the practical implications of achieving good stewardship, and we can all benefit from their insights gained during several years of working to improve antimicrobial prescribing.
8
Copyright 2001 Joint Commission on Accreditation of Healthcare Organizations
403
THE JOINT COMMISSION It is important to note that the authors do not claim to have all the answers but do describe the many pitfalls they have encountered in their efforts. At this time it is not clear to me what approach is ultimately best for increasing good stewardship. There may be no single answer to achieving good stewardship, but Schiff et al suggest that electronic computer ordering—so-called order entry—may be the ultimate answer. We use order entry in our hospital to reduce medication errors, and it is very successful, but even with order entry it is still possible to “perfectly order the wrong antibiotic” for a patient. That is, the dose, duration, drug compatibility, allergy compatibility, and adjustment for renal failure may all be done without error, but the choice of the antibiotic may be completely inappropriate. Preventing this occurrence will require development of computerized databases and software programming of a highly sophisticated level of quality that will incorporate all the best information from guidelines, hospital antibiograms, patientspecific microbiology cultures and susceptibility, the hospital formulary, and complete patient-specific laboratory and pharmacy data. Only a select few hospitals in the United States have this level of antibiotic decision support sophistication, and it will be many years before those systems can be deployed widely. In addition to good antimicrobial stewardship, there are other ways to reduce antimicrobial resistance. Although Schiff and colleagues do not discuss it, a highly effective method to control use of specific antimicrobials lies in removing them from the formu-
404
lary entirely or placing them in a restricted access status, limited to specific specialists. This draconian approach has been the most effective method to rapidly change antimicrobial use. Infection control committees I have sat on have employed these strategies for gentamicin and clindamycin and shown dramatic reductions in infections caused by specific organisms resistant to these drugs. Finally, as Schiff et al acknowledge, altering antimicrobial use might not address all antimicrobial resistance. Good infection control is absolutely critical to the prevention of horizontal spread of resistant organisms in the inpatient environment. After all, if every patient infected with MRSA (methicillinresistant Staphylococcus aureus) or VRE (vancomycinresistant Enterococcus) were to be prevented by rigorous infection control practices from transmitting the organism to another patient, we would readily eliminate most of these resistant organisms from our institutions. So until that computerized antimicrobial decision support system comes to your hospital, safeguard those antibiotics by practicing good antimicrobial stewardship, and don’t forget to wear gloves and wash your hands. J References 1. Schiff GD, et al: Improving inpatient antibiotic prescribing: Insights from participation in a national collaborative. Jt Comm J Qual Improv 27:387–402, 2001. 2. Shlaes DM, et al: Society for Healthcare Epidemiology of Amer-
ica and Infectious Diseases Society of America Joint Committee on the Prevention of Antimicrobial Resistance: Guidelines for the Prevention of Antimicrobial Resistance in Hospitals. Infect Control Hosp Epidemiol 8:275–291, 1997.
AUGUST 2001 JOURNAL Copyright 2001 Joint Commission on Accreditation of Healthcare Organizations