Letters
CDC antibiotic stewardship recommendations: One state’s assessment identifies need for compliance
I
n March 2014, the Centers for Disease Control and Prevention (CDC) publication Vital Signs brought antibiotic misuse into the public spotlight as a call to action for antibiotic stewardship.1 To preserve antibiotics for the future, CDC recommended that all hospitals adopt an antibiotic stewardship program (ASP) and provided a checklist of minimum requirements for stewardship programs. The core elements of this checklist contain more than 30 recommended measures and actions for a successful stewardship program.2 The Maryland Health Care Commission (MHCC) is an independent
regulatory agency whose mission includes planning for health-system needs. In light of CDC’s recommendations, along with a statewide initiative to promote antibiotic stewardship in Maryland, MHCC, through the Healthcare-Associated Infections Advisory Committee, surveyed the current state of stewardship as part of its annual Hospital Infection Prevention and Control Program Survey. The survey was sent to the lead infection preventionist at all 46 acute care hospitals in Maryland. All hospitals responded. Survey results (unpublished) were not verified or validated. The majority of hospitals in Maryland (38 of 46, 83%) currently have some
form of an ASP in place. The CDC checklist recommends that all facilities have a physician leader responsible for program outcomes for stewardship activities and a pharmacist leader responsible for working to improve antibiotic use. Of the 38 hospitals with a stewardship program in place, 50% had a physician responsible for ASP oversight and 50% had a pharmacist with a doctor of pharmacy degree and infectious diseases training or certification in stewardship. Of the 8 hospitals without an active program, 100% of respondents noted that pharmacy staffing was not adequate to provide support to a program, and 7 noted lack of access to an infectious diseases physician or pharmacist with infectious diseases training or certification in stewardship as a barrier to such a program. CDC recommends multiple specific interventions to improve antibiotic use, Continued on page 1834
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Letters Continued from page 1833
including a formal procedure to review the appropriateness of all antibiotics 48 hours after the initial order was placed, preauthorization of certain antibiotics, a prospective audit of and feedback regarding specific antibiotic agents, i.v.to-oral antibiotic changes, dose optimization, and automatic stop orders. The types of stewardship interventions performed at hospitals across Maryland varied widely. Fifty percent of the hospitals restricted the use of targeted antibiotics, with carbapenems being the most commonly targeted class. Forty-one percent of hospitals required that all antibiotics have an indication included on the order. Most hospitals with stewardship programs (19 of 38, 50%) used a postprescription review (within 72 hours) format compared with preprescription approval (9 of 38, 24%) or other stewardship strategies (10 of 38, 26%). No hospitals currently participate in the Antimicrobial Use and Resistance module of CDC’s National Healthcare Safety Network. Computerized prescriberorder-entry systems linked orders with stewardship activities in 50% of hospitals. Only 26% of the hospitals are using data-mining software programs such as SafetyAdvisor (Premier Inc., Charlotte, NC), TheraDoc (Premier Inc.), and Sentri
7 (Wolters Kluwer Health, Philadelphia, PA) as part of their ASP. CDC recommends a multifaceted approach for tracking the impact of a stewardship program through process measures (e.g., adherence to facility-specific treatment guidelines and interventions), antibiotic use, and outcomes measures. Potential outcomes measures include rates of Clostridium difficile infection and a facility-specific antibiogram to monitor resistance. Most hospitals (91%) did have an institutional antibiogram in place. Recommended antibiotic consumption metrics include antibiotic days of therapy (DOT), grams of antibiotic used as the defined daily dose (DDD), or direct expenditures as purchasing costs. In response to an open-ended question asking for metric specifications, only 20% of the hospitals indicated that antibiotic use is tracked as either DDD or DOT. While these survey results only represent a single state, they highlight the discordance between CDC recommendations for stewardship and what hospitals currently have in place. Although a majority of hospitals in Maryland have an ASP, program structure and metrics vary widely. In addition, many programs noted a lack of resources (personnel or IT support) to meet the recommended core items on the CDC checklist. The
CDC antibiotic stewardship campaign offers an important opportunity to promote the profession of pharmacy as a vital component of a successful ASP. 1. Centers for Disease Control and Prevention. Antibiotic Rx in hospitals: proceed with caution. Vital Signs, March 2014. w w w. cd c . g ov / v i t a l s i g n s / p d f / 2 0 1 4 03-vitalsigns.pdf (accessed 2014 Aug 12). 2. National Center for Emerging and Zoonotic Infectious Diseases. Core elements of hospital antibiotic stewardship programs. www.cdc.gov/getsmart/healthcare/ pdfs/checklist.pdf (accessed 2014 Apr 19).
Emily L. Heil, Pharm.D., BCPS-AQ ID, AAHIVP, Infectious Diseases Clinical Pharmacy Specialist Department of Pharmacy University of Maryland Medical Center Baltimore, MD [email protected] Jennifer Thomas, Pharm.D., Manager, Pharmacy Services Delmarva Foundation for Medical Care Columbia, MD
Dr. Heil is a member of the HealthcareAssociated Infections Advisory Committee of the Maryland Health Care Commission. The authors have declared no potential conflicts of interest. DOI 10.2146/ajhp140273
Statement of Ownership, Management and Circulation (Required by 39 U.S.C. 3685) 1. Title of publication, American Journal of HealthSystem Pharmacy. 2. Publication No. 1079-2082. 3. Date of filing, October 1, 2014. 4. Frequency of issue, Twice monthly. 5. No. issues published annually, 24. 6. Annual subscription price, $356.00. 7. Location of known office of publication, 7272 Wisconsin Avenue, Bethesda, Montgomery County, MD 20814-4836. 8. Location of the headquarters or general business offices of publishers, 7272 Wisconsin Avenue, Bethesda, MD 20814-4836. 9. Publisher, American Society of Health-System Pharmacists, Inc., 7272 Wisconsin Avenue, Bethesda, MD 20814-4836. Editor in Chief, C. Richard Talley, 7272 Wisconsin Avenue, Bethesda, MD 20814-4836. 10. Owner, American Society of Health-System Pharmacists, Inc., 7272 Wisconsin Avenue, Bethesda, MD 20814-4836. 11. Known bondholders, mortgagees, and other security holders owning 1% or more of total amount of bonds, mortgages, and other securities, None. 12. For completion by nonprofit organizations authorized to mail at special rates (Section 132.122, PSM). The purpose, function, and nonprofit status of this organization and the exempt status for federal income tax purposes have not changed during preceding 12 months. 13. Publication name, American Journal of Health-System Pharmacy. 14. Issue date for circulation data below, 9/15/2014. 15. Extent and nature of circulation, A. Total no. copies printed, 34,853/32,900*; B. Paid circulation, 1. Sales through dealers and carriers, street vendors, and counter sales, 300/0. 2. Paid or requested mail subscriptions, 33,051/32,333; C. Total paid or requested circulation, 33,351/32,333; D. Free distribution by mail, 505/181; E. Free distribution outside the mail, 0/0. F. Total free distribution, 492/206. G. Total distribution, 33,843/32,539; H. Copies not distributed, 1. Office use, left over, spoiled, 1,010/361. 2. Returns from news agents, 0, 0; I. Total, 34,853/32,900. Percent paid circulation, 98.5/99.4. I certify that the statements made by me are correct and complete, signed C. Richard Talley. *First figure, average no. copies of each issue during preceding 12 months; second figure, actual no. copies of single issue published nearest to filing date.
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Copyright of American Journal of Health-System Pharmacy is the property of American Society of Health System Pharmacists and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
CDC antibiotic stewardship recommendations: One state’s assessment identifies need for compliance
I
n March 2014, the Centers for Disease Control and Prevention (CDC) publication Vital Signs brought antibiotic misuse into the public spotlight as a call to action for antibiotic stewardship.1 To preserve antibiotics for the future, CDC recommended that all hospitals adopt an antibiotic stewardship program (ASP) and provided a checklist of minimum requirements for stewardship programs. The core elements of this checklist contain more than 30 recommended measures and actions for a successful stewardship program.2 The Maryland Health Care Commission (MHCC) is an independent
regulatory agency whose mission includes planning for health-system needs. In light of CDC’s recommendations, along with a statewide initiative to promote antibiotic stewardship in Maryland, MHCC, through the Healthcare-Associated Infections Advisory Committee, surveyed the current state of stewardship as part of its annual Hospital Infection Prevention and Control Program Survey. The survey was sent to the lead infection preventionist at all 46 acute care hospitals in Maryland. All hospitals responded. Survey results (unpublished) were not verified or validated. The majority of hospitals in Maryland (38 of 46, 83%) currently have some
form of an ASP in place. The CDC checklist recommends that all facilities have a physician leader responsible for program outcomes for stewardship activities and a pharmacist leader responsible for working to improve antibiotic use. Of the 38 hospitals with a stewardship program in place, 50% had a physician responsible for ASP oversight and 50% had a pharmacist with a doctor of pharmacy degree and infectious diseases training or certification in stewardship. Of the 8 hospitals without an active program, 100% of respondents noted that pharmacy staffing was not adequate to provide support to a program, and 7 noted lack of access to an infectious diseases physician or pharmacist with infectious diseases training or certification in stewardship as a barrier to such a program. CDC recommends multiple specific interventions to improve antibiotic use, Continued on page 1834
Am J Health-Syst Pharm—Vol 71 Nov 1, 2014
1833
Letters Continued from page 1833
including a formal procedure to review the appropriateness of all antibiotics 48 hours after the initial order was placed, preauthorization of certain antibiotics, a prospective audit of and feedback regarding specific antibiotic agents, i.v.to-oral antibiotic changes, dose optimization, and automatic stop orders. The types of stewardship interventions performed at hospitals across Maryland varied widely. Fifty percent of the hospitals restricted the use of targeted antibiotics, with carbapenems being the most commonly targeted class. Forty-one percent of hospitals required that all antibiotics have an indication included on the order. Most hospitals with stewardship programs (19 of 38, 50%) used a postprescription review (within 72 hours) format compared with preprescription approval (9 of 38, 24%) or other stewardship strategies (10 of 38, 26%). No hospitals currently participate in the Antimicrobial Use and Resistance module of CDC’s National Healthcare Safety Network. Computerized prescriberorder-entry systems linked orders with stewardship activities in 50% of hospitals. Only 26% of the hospitals are using data-mining software programs such as SafetyAdvisor (Premier Inc., Charlotte, NC), TheraDoc (Premier Inc.), and Sentri
7 (Wolters Kluwer Health, Philadelphia, PA) as part of their ASP. CDC recommends a multifaceted approach for tracking the impact of a stewardship program through process measures (e.g., adherence to facility-specific treatment guidelines and interventions), antibiotic use, and outcomes measures. Potential outcomes measures include rates of Clostridium difficile infection and a facility-specific antibiogram to monitor resistance. Most hospitals (91%) did have an institutional antibiogram in place. Recommended antibiotic consumption metrics include antibiotic days of therapy (DOT), grams of antibiotic used as the defined daily dose (DDD), or direct expenditures as purchasing costs. In response to an open-ended question asking for metric specifications, only 20% of the hospitals indicated that antibiotic use is tracked as either DDD or DOT. While these survey results only represent a single state, they highlight the discordance between CDC recommendations for stewardship and what hospitals currently have in place. Although a majority of hospitals in Maryland have an ASP, program structure and metrics vary widely. In addition, many programs noted a lack of resources (personnel or IT support) to meet the recommended core items on the CDC checklist. The
CDC antibiotic stewardship campaign offers an important opportunity to promote the profession of pharmacy as a vital component of a successful ASP. 1. Centers for Disease Control and Prevention. Antibiotic Rx in hospitals: proceed with caution. Vital Signs, March 2014. w w w. cd c . g ov / v i t a l s i g n s / p d f / 2 0 1 4 03-vitalsigns.pdf (accessed 2014 Aug 12). 2. National Center for Emerging and Zoonotic Infectious Diseases. Core elements of hospital antibiotic stewardship programs. www.cdc.gov/getsmart/healthcare/ pdfs/checklist.pdf (accessed 2014 Apr 19).
Emily L. Heil, Pharm.D., BCPS-AQ ID, AAHIVP, Infectious Diseases Clinical Pharmacy Specialist Department of Pharmacy University of Maryland Medical Center Baltimore, MD [email protected] Jennifer Thomas, Pharm.D., Manager, Pharmacy Services Delmarva Foundation for Medical Care Columbia, MD
Dr. Heil is a member of the HealthcareAssociated Infections Advisory Committee of the Maryland Health Care Commission. The authors have declared no potential conflicts of interest. DOI 10.2146/ajhp140273
Statement of Ownership, Management and Circulation (Required by 39 U.S.C. 3685) 1. Title of publication, American Journal of HealthSystem Pharmacy. 2. Publication No. 1079-2082. 3. Date of filing, October 1, 2014. 4. Frequency of issue, Twice monthly. 5. No. issues published annually, 24. 6. Annual subscription price, $356.00. 7. Location of known office of publication, 7272 Wisconsin Avenue, Bethesda, Montgomery County, MD 20814-4836. 8. Location of the headquarters or general business offices of publishers, 7272 Wisconsin Avenue, Bethesda, MD 20814-4836. 9. Publisher, American Society of Health-System Pharmacists, Inc., 7272 Wisconsin Avenue, Bethesda, MD 20814-4836. Editor in Chief, C. Richard Talley, 7272 Wisconsin Avenue, Bethesda, MD 20814-4836. 10. Owner, American Society of Health-System Pharmacists, Inc., 7272 Wisconsin Avenue, Bethesda, MD 20814-4836. 11. Known bondholders, mortgagees, and other security holders owning 1% or more of total amount of bonds, mortgages, and other securities, None. 12. For completion by nonprofit organizations authorized to mail at special rates (Section 132.122, PSM). The purpose, function, and nonprofit status of this organization and the exempt status for federal income tax purposes have not changed during preceding 12 months. 13. Publication name, American Journal of Health-System Pharmacy. 14. Issue date for circulation data below, 9/15/2014. 15. Extent and nature of circulation, A. Total no. copies printed, 34,853/32,900*; B. Paid circulation, 1. Sales through dealers and carriers, street vendors, and counter sales, 300/0. 2. Paid or requested mail subscriptions, 33,051/32,333; C. Total paid or requested circulation, 33,351/32,333; D. Free distribution by mail, 505/181; E. Free distribution outside the mail, 0/0. F. Total free distribution, 492/206. G. Total distribution, 33,843/32,539; H. Copies not distributed, 1. Office use, left over, spoiled, 1,010/361. 2. Returns from news agents, 0, 0; I. Total, 34,853/32,900. Percent paid circulation, 98.5/99.4. I certify that the statements made by me are correct and complete, signed C. Richard Talley. *First figure, average no. copies of each issue during preceding 12 months; second figure, actual no. copies of single issue published nearest to filing date.
1834
Am J Health-Syst Pharm—Vol 71 Nov 1, 2014
Copyright of American Journal of Health-System Pharmacy is the property of American Society of Health System Pharmacists and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
