Journal of Hospital Infection xxx (2015) 1e3 Available online at www.sciencedirect.com
Journal of Hospital Infection journal homepage: www.elsevierhealth.com/journals/jhin
Antibiotic stewardship programmes and the surgeon’s role M. C ¸akmakc ¸i* Anadolu Saglik Merkezi, Kocaeli, Turkey
A R T I C L E
I N F O
Article history: Received 14 November 2014 Accepted 6 January 2015 Available online xxx Keywords: Antibiotic resistance Antibiotic stewardship Complications Patient safety Quality of care Surgery
S U M M A R Y
Inappropriate antibiotic use is a frequent occurrence, especially in surgical units. Among the unnecessary costs of such usage are unfavourable outcomes for patients and the emergence and spread of resistant bacteria. Antibiotic stewardship programmes aim to limit the spread of antibiotic resistance by promoting thoughtful prescribing of antibiotics. Such programmes usually try to control inappropriate use of antibiotics; to optimize the choice of drug, dosing, route, and duration of therapy; to maximize clinical cure or prevention of infection; and to limit unwanted effects and excess cost. In this paper, I discuss the impact of improper use of antibiotics and outline why I believe that antibiotic stewardship is likely to be the best way of dealing with it. Engagement of surgeons in antibiotic stewardship programmes is crucial to their success. ª 2015 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.
Antibiotic stewardship Antibiotics are among the most frequently used drugs in hospitals. According to a study of drug use in 323 US hospitals in 2010, 56% of patients were given an antibiotic during their hospital stay, and 30% received at least one dose of broadspectrum antibiotics.1 Despite this heavy usage, up to 50% of antibiotic prescriptions have been found to be for inappropriate indications, the wrong agents, or wrong duration of therapy.2 One recent report revealed that 30% of antibiotic treatment days for hospitalized adult patients not in critical care units were unnecessary; antibiotics were often used for longer than recommended, or for improper ‘treatment’ of colonizing or contaminating micro-organisms.3 Misuse of * Address: Anadolu Caddesi No. 1 Bayramoglu, C ¸ ıkıs‚ı C ¸ ayırova Mevkii ‒ Gebze, Kocaeli, 41400, Turkey. Tel.: þ90 44 44 276. E-mail address: [email protected].
antibiotics in this way results in unnecessary morbidity and mortality, as well as substantially increased healthcare costs. It also contributes to a major emerging public health problem. These unwanted outcomes are mainly due to: e e e e
the emergence and selection of resistant micro-organisms; antimicrobial drug toxicity and complications; other nosocomial infections; prolonged hospitalization.
Complications of antibiotics can be directly associated with the drug, or can be indirect consequences such as catheter infection associated with intravenous administration. The increased rate of Clostridium difficile infections is a prime example of harm caused by selection of resistant microorganisms. The US Centers for Disease Control and Prevention estimate that around 250,000 C. difficile infections in US hospitals per annum result in 14,000 deaths.2 The increasing
http://dx.doi.org/10.1016/j.jhin.2015.01.006 0195-6701/ª 2015 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved. Please cite this article in press as: C ¸ akmakc ¸i M, Antibiotic stewardship programmes and the surgeon’s role, Journal of Hospital Infection (2015), http://dx.doi.org/10.1016/j.jhin.2015.01.006
2
M. C ¸ akmakc¸i / Journal of Hospital Infection xxx (2015) 1e3
prevalence of antibiotic-resistant pathogens and the limited number of new antibiotics in development combine to make antibiotic resistance a serious global healthcare problem. In 2013 it was estimated that every year two million people in the USA acquire serious infections with resistant bacteria, and that at least 23,000 people die as a direct result of these infections.2 Concentrating on proper antibiotic use is a realistic approach to this problem, and arguably the most important one. Surgical units deserve special attention. A study at the University Hospital Zurich found that in addition to high overall inappropriate use, there were substantial differences between medical and surgical wards in the ‘error rate’ of antibiotic prescriptions.4 In this analysis, 32% of antibiotic prescriptions overall were judged as inappropriate, with prescriptions for treatment being more frequently inappropriate than those for prophylaxis (37.0% vs 16.6%). Among the prescriptions for treatment of infection, there was no solid indication in 17.5%, an inappropriate drug was chosen in 7.6%, and the application was incorrect in 9.3% (Table I). The highest rate of improper therapeutic antibiotic use was in the surgical ward, the main problem being lack of indication in 30.3% of instances, including pre-emptive antibiotic therapy after surgical interventions. In surgical wards overall, nearly half of the antimicrobial use was assessed as inappropriate.4 Surgical patients are also more vulnerable. A retrospective review of 114,677 hospitalized patients in a single, tertiary centre between 2009 and 2011 found that surgical patients who developed infection complications had a higher mortality than did non-surgical patients with infection complications (14.4% vs 3.7%, P < 0.001). Putting all complications together, there was significantly higher mortality in surgical patients with complications than in non-surgical patients experiencing similar harms (73.2% vs 37%, P < 0.001).5 Inappropriate antimicrobial prescribing is generally related to lack of knowledge of, and training in, diagnosis and treatment of infectious diseases (Box 1). This seems to be especially true of surgeons. Most surgical training programmes do not incorporate any teaching on surgical infections and antibiotic usage. Having served as board member and president in the Surgical Infection Society ‒ Europe for over a decade, I feel that the interest and awareness in surgical infections among practising surgeons is not just very low; it is also declining. Most healthcare priorities today deal with quality of care on the one hand and patient safety on the other. Better control and use of antibiotics could be important contributors to both. Antibiotic stewardship programmes aim to limit the spread of antibiotic resistance by promoting thoughtful prescribing of antibiotics. They are advocated by organizations including the
Box 1 Reasons for inappropriate antimicrobial use e Uncertainty of the diagnosis e Lack of training, experience or confidence of physicians e Lack of knowledge of local epidemiology of antimicrobial resistance e Misinterpretation of microbiological results e Lack of guidance and institutional leadership
Infectious Diseases Society of America in conjunction with the Society for Healthcare Epidemiology of America, the American Society of Health System Pharmacists, and The Joint Commission.6e12 Antibiotic stewardship programmes usually try to control inappropriate use of antibiotics; to optimize the choice of drug, dosing, route, and duration of therapy; to maximize clinical cure or prevention of infection; and to limit unwanted effects and excess cost. They are one of the most effective ways of optimizing the treatment of infections, reducing adverse events resulting from antibiotic use, and improving patient safety. The core elements are listed in Box 2. Various studies show that antibiotic stewardship programmes improve antibiotic usage. The outcomes also improve: better medical results, reduced antibiotic-related adverse events, reduced readmissions, and reduced antibiotic resistance. A study showed that under antibiotic stewardship cure of infections increased by 70% and treatment failures decreased by 80%.6 Getting active surgeons and surgical leaders more involved in present and planned antibiotic stewardship programmes would, I believe, enhance those outcomes. But we need a major shift in mind-set, from one that regards antibiotic stewardship as a cost-saving programme, to one which sees it as essential for patient safety and quality improvement. The primary purpose has to be the optimization of clinical outcomes. Surgeons are not unfamiliar with quality improvement programmes, and are willing to co-operate, especially if the outcomes for their patients are likely to improve. The Surgical Care Improvement Project (SCIP), committed to improving the safety of surgical care through the reduction of postoperative complications, especially surgical site infections, is a good example.13 Antibiotic stewardship programmes also improve attitudes to surgical antibiotic prophylaxis. Also, appropriate prophylaxis prevents surgical site infections and reduces potential adverse events. We should not forget that nearly half of antibiotics are consumed in surgical clinics. Antibiotic stewardship programmes are probably the most effective way of controlling the spread of antibiotic
Table I Inappropriate therapeutic use of antibiotics in various hospital units (expressed as a percentage of antibiotic prescriptions)a
Total inappropriate prescriptions Inappropriate indication Inappropriate choice of antibiotic Inappropriate dose, timing, route, or duration Divergence from internal guidelines a
All wards
Surgical wards
Medical wards
Intensive care unit
Haematology/ oncology wards
37.0% 17.5% 7.6% 9.3% 8.0%
49.3% 30.3% 10.9% 9.5% 0.9%
32.9% 11.6% 8.4% 9.9% 11.0%
32.4% 18.4% 7.8% 6.7% 6.7%
36.0% 14.0% 2.8% 10.3% 11.2%
From Cusini et al.4
Please cite this article in press as: C ¸ akmakc ¸i M, Antibiotic stewardship programmes and the surgeon’s role, Journal of Hospital Infection (2015), http://dx.doi.org/10.1016/j.jhin.2015.01.006
M. C ¸ akmakc¸i / Journal of Hospital Infection xxx (2015) 1e3 Box 2 Seven core elements critical to the success of hospital antibiotic stewardship programmesa e Leadership commitment: dedicating necessary human, financial, and information technology resources. e Accountability: appointing a single leader responsible for programme outcomes. Experience with successful programmes has shown that a physician leader is effective. e Drug expertise: appointing a single pharmacist leader responsible for working to improve antibiotic use. e Action: implementing at least one recommended action, such as systematic evaluation of ongoing treatment needed after a set period of initial treatment (i.e. ‘antibiotic time-out’ after 48 h). e Tracking: monitoring antibiotic prescribing and resistance patterns. e Reporting: regular reporting information on antibiotic usage and resistance to doctors, nurses, and relevant staff members. e Education: educating clinicians about resistance and optimal prescribing. a
From the US Centers of Disease Control and Prevention.11
resistance and enhancing patient safety. However, antibiotic stewardship needs to be implemented more effectively and surgeons need to have a central role in it. Conflict of interest statement None declared. Funding sources None.
References
3
2. US Centers for Disease Control and Prevention. Antibiotic resistance threats in the United States, 2013. http://www.cdc.gov/ drugresistance/threat-report-2013/ [accessed 24.12.14]. 3. Hecker MT, Aron DC, Patel NP, Lehmann MK, Donskey CJ. Unnecessary use of antimicrobials in hospitalized patients: current patterns of misuse with an emphasis on the antianaerobic spectrum of activity. Archs Intern Med 2003;163:972e978. 4. Cusini A, Rampini SK, Bansal V, et al. Different patterns of inappropriate antimicrobial use in surgical and medical units at a tertiary care hospital in Switzerland: a prevalence survey. PLOS One 2010;(5):e14011. 5. Bauman Z, Gassner M, Host H, et al. Causes of surgical mortality: is it pathology or hospital harms? Crit Care Med 2013;41. Abstract 31. 6. Fishman N. Antimicrobial stewardship. Am J Med 2006;119(6 Suppl. 1):S53eS61. 7. Dellit TH, Owens RC, McGowan JE, et al. Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clin Infect Dis 2007;44:159e177. 8. File TM, Solomkin JS, Cosgrove SE. Strategies for improving antimicrobial use and the role of antimicrobial stewardship programs. Clin Infect Dis 2011;53(Suppl. 1):S15eS22. 9. McGowan JE. Antimicrobial stewardship ‒ the state of the art in 2011: focus on outcome and methods. Infect Control Hosp Epidemiol 2012;33:331e337. 10. Nowak MA, Nelson RE, Breidenbach JL, et al. Clinical and economic outcomes of a prospective antimicrobial stewardship program. Am J Health Syst Pharm 2012;69:1500e1508. 11. US Centers for Disease Control and Prevention. Core elements of hospital antibiotic stewardship programs. http://www.cdc.gov/ getsmart/healthcare/implementation/core-elements.html. Last updated: March 4th, 2014. 12. File TM, Srinivasan A, Bartlett JG. Antimicrobial stewardship: importance for patient and public health. Clin Infect Dis 2014;59(Suppl. 3):S93eS96. 13. Cataife G, Weinberg DA, Wong HH, Kahn KL. The effect of Surgical Care Improvement Project (SCIP) compliance on surgical site infections (SSI). Med Care 2014;52(2 Suppl. 1):S66eS73.
1. Fridkin SK, Baggs J, Fagan R, et al. Improving antibiotic use among hospitalized patients. Morb Mortal Wkly Rep 2014;63:1e7.
Please cite this article in press as: C ¸ akmakc ¸i M, Antibiotic stewardship programmes and the surgeon’s role, Journal of Hospital Infection (2015), http://dx.doi.org/10.1016/j.jhin.2015.01.006
Journal of Hospital Infection journal homepage: www.elsevierhealth.com/journals/jhin
Antibiotic stewardship programmes and the surgeon’s role M. C ¸akmakc ¸i* Anadolu Saglik Merkezi, Kocaeli, Turkey
A R T I C L E
I N F O
Article history: Received 14 November 2014 Accepted 6 January 2015 Available online xxx Keywords: Antibiotic resistance Antibiotic stewardship Complications Patient safety Quality of care Surgery
S U M M A R Y
Inappropriate antibiotic use is a frequent occurrence, especially in surgical units. Among the unnecessary costs of such usage are unfavourable outcomes for patients and the emergence and spread of resistant bacteria. Antibiotic stewardship programmes aim to limit the spread of antibiotic resistance by promoting thoughtful prescribing of antibiotics. Such programmes usually try to control inappropriate use of antibiotics; to optimize the choice of drug, dosing, route, and duration of therapy; to maximize clinical cure or prevention of infection; and to limit unwanted effects and excess cost. In this paper, I discuss the impact of improper use of antibiotics and outline why I believe that antibiotic stewardship is likely to be the best way of dealing with it. Engagement of surgeons in antibiotic stewardship programmes is crucial to their success. ª 2015 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.
Antibiotic stewardship Antibiotics are among the most frequently used drugs in hospitals. According to a study of drug use in 323 US hospitals in 2010, 56% of patients were given an antibiotic during their hospital stay, and 30% received at least one dose of broadspectrum antibiotics.1 Despite this heavy usage, up to 50% of antibiotic prescriptions have been found to be for inappropriate indications, the wrong agents, or wrong duration of therapy.2 One recent report revealed that 30% of antibiotic treatment days for hospitalized adult patients not in critical care units were unnecessary; antibiotics were often used for longer than recommended, or for improper ‘treatment’ of colonizing or contaminating micro-organisms.3 Misuse of * Address: Anadolu Caddesi No. 1 Bayramoglu, C ¸ ıkıs‚ı C ¸ ayırova Mevkii ‒ Gebze, Kocaeli, 41400, Turkey. Tel.: þ90 44 44 276. E-mail address: [email protected].
antibiotics in this way results in unnecessary morbidity and mortality, as well as substantially increased healthcare costs. It also contributes to a major emerging public health problem. These unwanted outcomes are mainly due to: e e e e
the emergence and selection of resistant micro-organisms; antimicrobial drug toxicity and complications; other nosocomial infections; prolonged hospitalization.
Complications of antibiotics can be directly associated with the drug, or can be indirect consequences such as catheter infection associated with intravenous administration. The increased rate of Clostridium difficile infections is a prime example of harm caused by selection of resistant microorganisms. The US Centers for Disease Control and Prevention estimate that around 250,000 C. difficile infections in US hospitals per annum result in 14,000 deaths.2 The increasing
http://dx.doi.org/10.1016/j.jhin.2015.01.006 0195-6701/ª 2015 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved. Please cite this article in press as: C ¸ akmakc ¸i M, Antibiotic stewardship programmes and the surgeon’s role, Journal of Hospital Infection (2015), http://dx.doi.org/10.1016/j.jhin.2015.01.006
2
M. C ¸ akmakc¸i / Journal of Hospital Infection xxx (2015) 1e3
prevalence of antibiotic-resistant pathogens and the limited number of new antibiotics in development combine to make antibiotic resistance a serious global healthcare problem. In 2013 it was estimated that every year two million people in the USA acquire serious infections with resistant bacteria, and that at least 23,000 people die as a direct result of these infections.2 Concentrating on proper antibiotic use is a realistic approach to this problem, and arguably the most important one. Surgical units deserve special attention. A study at the University Hospital Zurich found that in addition to high overall inappropriate use, there were substantial differences between medical and surgical wards in the ‘error rate’ of antibiotic prescriptions.4 In this analysis, 32% of antibiotic prescriptions overall were judged as inappropriate, with prescriptions for treatment being more frequently inappropriate than those for prophylaxis (37.0% vs 16.6%). Among the prescriptions for treatment of infection, there was no solid indication in 17.5%, an inappropriate drug was chosen in 7.6%, and the application was incorrect in 9.3% (Table I). The highest rate of improper therapeutic antibiotic use was in the surgical ward, the main problem being lack of indication in 30.3% of instances, including pre-emptive antibiotic therapy after surgical interventions. In surgical wards overall, nearly half of the antimicrobial use was assessed as inappropriate.4 Surgical patients are also more vulnerable. A retrospective review of 114,677 hospitalized patients in a single, tertiary centre between 2009 and 2011 found that surgical patients who developed infection complications had a higher mortality than did non-surgical patients with infection complications (14.4% vs 3.7%, P < 0.001). Putting all complications together, there was significantly higher mortality in surgical patients with complications than in non-surgical patients experiencing similar harms (73.2% vs 37%, P < 0.001).5 Inappropriate antimicrobial prescribing is generally related to lack of knowledge of, and training in, diagnosis and treatment of infectious diseases (Box 1). This seems to be especially true of surgeons. Most surgical training programmes do not incorporate any teaching on surgical infections and antibiotic usage. Having served as board member and president in the Surgical Infection Society ‒ Europe for over a decade, I feel that the interest and awareness in surgical infections among practising surgeons is not just very low; it is also declining. Most healthcare priorities today deal with quality of care on the one hand and patient safety on the other. Better control and use of antibiotics could be important contributors to both. Antibiotic stewardship programmes aim to limit the spread of antibiotic resistance by promoting thoughtful prescribing of antibiotics. They are advocated by organizations including the
Box 1 Reasons for inappropriate antimicrobial use e Uncertainty of the diagnosis e Lack of training, experience or confidence of physicians e Lack of knowledge of local epidemiology of antimicrobial resistance e Misinterpretation of microbiological results e Lack of guidance and institutional leadership
Infectious Diseases Society of America in conjunction with the Society for Healthcare Epidemiology of America, the American Society of Health System Pharmacists, and The Joint Commission.6e12 Antibiotic stewardship programmes usually try to control inappropriate use of antibiotics; to optimize the choice of drug, dosing, route, and duration of therapy; to maximize clinical cure or prevention of infection; and to limit unwanted effects and excess cost. They are one of the most effective ways of optimizing the treatment of infections, reducing adverse events resulting from antibiotic use, and improving patient safety. The core elements are listed in Box 2. Various studies show that antibiotic stewardship programmes improve antibiotic usage. The outcomes also improve: better medical results, reduced antibiotic-related adverse events, reduced readmissions, and reduced antibiotic resistance. A study showed that under antibiotic stewardship cure of infections increased by 70% and treatment failures decreased by 80%.6 Getting active surgeons and surgical leaders more involved in present and planned antibiotic stewardship programmes would, I believe, enhance those outcomes. But we need a major shift in mind-set, from one that regards antibiotic stewardship as a cost-saving programme, to one which sees it as essential for patient safety and quality improvement. The primary purpose has to be the optimization of clinical outcomes. Surgeons are not unfamiliar with quality improvement programmes, and are willing to co-operate, especially if the outcomes for their patients are likely to improve. The Surgical Care Improvement Project (SCIP), committed to improving the safety of surgical care through the reduction of postoperative complications, especially surgical site infections, is a good example.13 Antibiotic stewardship programmes also improve attitudes to surgical antibiotic prophylaxis. Also, appropriate prophylaxis prevents surgical site infections and reduces potential adverse events. We should not forget that nearly half of antibiotics are consumed in surgical clinics. Antibiotic stewardship programmes are probably the most effective way of controlling the spread of antibiotic
Table I Inappropriate therapeutic use of antibiotics in various hospital units (expressed as a percentage of antibiotic prescriptions)a
Total inappropriate prescriptions Inappropriate indication Inappropriate choice of antibiotic Inappropriate dose, timing, route, or duration Divergence from internal guidelines a
All wards
Surgical wards
Medical wards
Intensive care unit
Haematology/ oncology wards
37.0% 17.5% 7.6% 9.3% 8.0%
49.3% 30.3% 10.9% 9.5% 0.9%
32.9% 11.6% 8.4% 9.9% 11.0%
32.4% 18.4% 7.8% 6.7% 6.7%
36.0% 14.0% 2.8% 10.3% 11.2%
From Cusini et al.4
Please cite this article in press as: C ¸ akmakc ¸i M, Antibiotic stewardship programmes and the surgeon’s role, Journal of Hospital Infection (2015), http://dx.doi.org/10.1016/j.jhin.2015.01.006
M. C ¸ akmakc¸i / Journal of Hospital Infection xxx (2015) 1e3 Box 2 Seven core elements critical to the success of hospital antibiotic stewardship programmesa e Leadership commitment: dedicating necessary human, financial, and information technology resources. e Accountability: appointing a single leader responsible for programme outcomes. Experience with successful programmes has shown that a physician leader is effective. e Drug expertise: appointing a single pharmacist leader responsible for working to improve antibiotic use. e Action: implementing at least one recommended action, such as systematic evaluation of ongoing treatment needed after a set period of initial treatment (i.e. ‘antibiotic time-out’ after 48 h). e Tracking: monitoring antibiotic prescribing and resistance patterns. e Reporting: regular reporting information on antibiotic usage and resistance to doctors, nurses, and relevant staff members. e Education: educating clinicians about resistance and optimal prescribing. a
From the US Centers of Disease Control and Prevention.11
resistance and enhancing patient safety. However, antibiotic stewardship needs to be implemented more effectively and surgeons need to have a central role in it. Conflict of interest statement None declared. Funding sources None.
References
3
2. US Centers for Disease Control and Prevention. Antibiotic resistance threats in the United States, 2013. http://www.cdc.gov/ drugresistance/threat-report-2013/ [accessed 24.12.14]. 3. Hecker MT, Aron DC, Patel NP, Lehmann MK, Donskey CJ. Unnecessary use of antimicrobials in hospitalized patients: current patterns of misuse with an emphasis on the antianaerobic spectrum of activity. Archs Intern Med 2003;163:972e978. 4. Cusini A, Rampini SK, Bansal V, et al. Different patterns of inappropriate antimicrobial use in surgical and medical units at a tertiary care hospital in Switzerland: a prevalence survey. PLOS One 2010;(5):e14011. 5. Bauman Z, Gassner M, Host H, et al. Causes of surgical mortality: is it pathology or hospital harms? Crit Care Med 2013;41. Abstract 31. 6. Fishman N. Antimicrobial stewardship. Am J Med 2006;119(6 Suppl. 1):S53eS61. 7. Dellit TH, Owens RC, McGowan JE, et al. Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clin Infect Dis 2007;44:159e177. 8. File TM, Solomkin JS, Cosgrove SE. Strategies for improving antimicrobial use and the role of antimicrobial stewardship programs. Clin Infect Dis 2011;53(Suppl. 1):S15eS22. 9. McGowan JE. Antimicrobial stewardship ‒ the state of the art in 2011: focus on outcome and methods. Infect Control Hosp Epidemiol 2012;33:331e337. 10. Nowak MA, Nelson RE, Breidenbach JL, et al. Clinical and economic outcomes of a prospective antimicrobial stewardship program. Am J Health Syst Pharm 2012;69:1500e1508. 11. US Centers for Disease Control and Prevention. Core elements of hospital antibiotic stewardship programs. http://www.cdc.gov/ getsmart/healthcare/implementation/core-elements.html. Last updated: March 4th, 2014. 12. File TM, Srinivasan A, Bartlett JG. Antimicrobial stewardship: importance for patient and public health. Clin Infect Dis 2014;59(Suppl. 3):S93eS96. 13. Cataife G, Weinberg DA, Wong HH, Kahn KL. The effect of Surgical Care Improvement Project (SCIP) compliance on surgical site infections (SSI). Med Care 2014;52(2 Suppl. 1):S66eS73.
1. Fridkin SK, Baggs J, Fagan R, et al. Improving antibiotic use among hospitalized patients. Morb Mortal Wkly Rep 2014;63:1e7.
Please cite this article in press as: C ¸ akmakc ¸i M, Antibiotic stewardship programmes and the surgeon’s role, Journal of Hospital Infection (2015), http://dx.doi.org/10.1016/j.jhin.2015.01.006
