The New War on Bugs: Crafting an Effective Antibiotic Stewardship Program (Arjun Srinivasan)

CAPT Arjun Srinivasan, MD Associate Director for Healthcare Associated

Infection Prevention Programs Division of Healthcare Quality Promotion

beu8@cdc.gov

Antibiotic Stewardship Why We Must How We Can

Begin With the End In Mind: The Goal

•  All patients in all hospitals get antibiotics: – Only when they are needed – Tailored to their infection – At the right time – At the right dose – For the right duration

Antibiotics are misused in hospitals

•  “It has been recognized for several decades that up to 50% of antimicrobial use is inappropriate”

•  IDSA/SHEA Guidelines for Antimicrobial Stewardship Programs

•  http://www.journals.uchicago.edu/doi/pdf/10.1086/510393

How Do We Reach Our Goal? •  Studies consistently show that the best way to

optimize outcomes related to antibiotic use in hospitals is through a program specifically dedicated to address this issue- an antibiotic stewardship program. – CDC believes all hospitals should have an

antibiotic stewardship program. – The American Hospital Association lists antibiotic

stewardship as one of the Top 5 ways hospitals can improve resource use.

Proven Benefits of Antibiotic Stewardship Programs in Hospitals •  Improved infection cure rates •  Reduced rates of complications due to

antibiotic use: – Fewer cases of Clostridium difficile – Fewer cases of antibiotic related adverse events

•  Reduced rates of antibiotic resistance •  Cost savings

Implementing Antibiotic Stewardship Programs

q Hospitals don’t all look the same, and neither do stewardship programs.

q There must be flexibility in how programs are implemented.

q But, there are certain key elements that have been strongly associated with success.

Core Elements for Antibiotic Stewardship Programs

http://www.cdc.gov/getsmart/healthcare/implementation/core-elements.html

Core Elements for Antibiotic Stewardship Programs

q Leadership commitment from administration q Single leader responsible for outcomes q Single pharmacy leader q Antibiotic use tracking q Regular reporting on antibiotic use and

resistance q Educating providers on use and resistance q Specific improvement interventions

Antibiotic Stewardship Programs in US Hospitals- 2014

q  In 2014, 39.2% of US hospitals reporting having a stewardship program that meets all 7 CDC Core Elements.

q Factors associated with meeting all Core Elements §  Larger bed size §  Teaching Status §  Leadership support (written > salary)

Preliminary findings from NHSN 2015 Annual Facility Survey - Not for distribution

Next Steps for Implementing Stewardship Programs in Hospitals •  CDC is working with many partners through

the National Quality Partnership to help identify ways to help hospitals implement stewardship programs that incorporate the core elements.

•  But just having stewardship programs is not enough.

What We Need to Optimize Antibiotic Use in Hospitals

q Education and Training- on interventions and implementation

q Measurement §  Total antibiotic use and appropriate use §  Prevalence of stewardship programs

q Research to expand implementation and develop new interventions.

q National goals q National policies

Measuring Antibiotic Use in Hospitals

•  We don’t have good data on antibiotic use in hospitals.

•  In 2012, CDC launched the Antibiotic Use (AU) Option of the National Healthcare Safety Network to address this problem.

•  The AU Option allows hospitals to electronically report antibiotic use data to CDC.

•  Having a measurement system creates a platform for antibiotic use benchmarking.

Standardized Antibiotic Administration Ratio (SAAR)

q CDC’s 1st attempt at developing a quality improvement, benchmarking measure for antibiotic use.

q Similar in principle to the Standardized Infection Ratio (SIR). §  SAAR expresses observed antibiotic use compared

to predicted use. q CDC worked with many partners to develop

the SAAR measure to try and make it most useful for stewardship.

Key Points About the SAAR

q The SAAR only helps directs stewardship efforts to locations and antibiotics where use appears to deviate from expected. § High use might be perfectly justified, low use

might be harming patients. q CDC is working with a variety of hospitals

who are reporting antibiotic use data to best determine how to use the SAAR to drive improvements.

National Goal and Policies

National Strategy for Combating Antibiotic Resistant Bacteria-

2020 Goals q  All states will implement stewardship activities in

healthcare settings. q  All federal facilities will have robust stewardship

programs. q  95% of hospitals will report antibiotic use data to

NHSN. q  Reduce inappropriate use for monitored conditions/

agents by 20% in hospitals

National Policies to Improve Antibiotic Use in Hospitals

•  Presidential advisors, along with various professional organizations, have called on the Center for Medicare and Medicaid Services to include antibiotic stewardship programs in the hospital Conditions of Participation.

•  Presidential advisors on antibiotic resistance have recommended that antibiotic use measures become part of the inpatient quality reporting program.

Conclusion

•  A lot is happening now to improve antibiotic use in hospitals.

•  It will take a village- the challenge is big and complex enough that no group can solve it alone.

•  I look forward to hearing your thoughts on ways we can work together.