MIAMI BEACH – More than half of acute care hospitals in Florida feature a formal antimicrobial stewardship program, and a sizable minority plans to launch one in the next year, according to a survey.
Antimicrobial resistance "is one of the most serious problems globally. Studies from acute and long-term care facilities have shown 30%-50% of antimicrobial use is inappropriate," Dr. Lilian M. Abbo said at the Florida Antimicrobial Stewardship Symposium sponsored by the University of Miami.
Dr. Lilian M. Abbo
Many hospitals already employ components of antimicrobial stewardship, such as formulary restrictions; requiring prescription preauthorizations; or post-prescribing reviews with feedback to the clinician. However, proponents point to better patient outcomes, lower resistance rates, and overall cost savings for hospitals through formal programs.
The positive outcomes demonstrated by the Florida survey could be applied nationwide, said Dr. Abbo, a clinical faculty member in the division of infectious diseases at the University of Miami Hospital.
The electronic survey in Florida revealed that 55% of 85 acute care facility respondents have a stewardship program and another 21% plan to join their ranks soon. "Of the 24% who said ‘no,’ 80% agreed a program would be useful," said Dr. Abbo, who is also the medical director of the Antimicrobial Stewardship Program at University of Miami Hospital/Jackson Memorial Medical Center.
Clostridium difficile, methicillin-resistant Staphylococcus aureus (MRSA), and multi-drug resistant gram-negative bacteria, in order, were the most troubling microbes reported. Specifically, when asked to identify their most challenging health care–associated infection, 33% of respondents cited C. difficile, 23% MRSA, and 19% the gram-negative bacteria.
So how are the facilities with formal stewardship programs combating this? The leading initiatives cited by 56 such hospitals including monitoring high-cost agents (52 hospitals or 93%), assessment of intravenous to oral conversions by 84%, and review of broad-spectrum agent use by 80%.
Specific agents under scrutiny through stewardship include linezolid (cited by 92% of respondents with a program), vancomycin (88%), and daptomycin (87%).
Outcomes associated with stewardship are one of the most difficult factors to measure, Dr. Abbo said. A total 70% of respondents with a program said they could demonstrate a decrease in drug purchasing costs, for example. Another 66% could show a reduction in antimicrobial resistance, and 66% a decrease in C. difficile infections. Other results show 64% can support lower antimicrobial consumption, 43% improved patient outcomes, 38% reduced length of stay, and 34% reduced adverse drug reactions associated with antibiotic use.
Stewardship programs that foster appropriate prescribing can save money. "That’s another important take-home message," Dr. Abbo said. "Cost savings are important. That is how you can negotiate with your CEO or CMO – that’s how you are going to save money for the hospital and more than pay for your salary."
In a practical move, the survey also examined barriers to implementation of stewardship programs. Of 76 responses, 66% cited personnel shortages, 64% cited time constraints, and 62% said funding is limited. Only 13% reported resistance from administration. "I was very impressed that most people do not feel their administrations are a barrier," Dr. Abbo said.
It takes a village to run an optimal stewardship program – another major theme from the results. "Stewardship cannot be done by one person alone," Dr. Abbo said. Efforts are multidisciplinary, with hospitalists involved in 23% of existing programs or those planned for the subsequent 12 months, the survey shows. Infectious disease physicians are involved in 55%, followed by clinical PharmDs (52%), infection control professionals (47%), and microbiologists (31%).
The majority of respondents, 62%, work at community hospitals. Another 10% each work at a city/county hospital or a nonuniversity teaching hospital. The remaining respondents hail from a university (adult or pediatric) hospital (6%), a community pediatric hospital (2%), a VA or military hospital (2%), or another acute care facility setting (8%).
A total 62% of facilities had between 100 and 500 beds. Only 11% had fewer than 100 beds, and 15% had more than 500 and up to 800 beds. The remaining 12% of facilities, the largest had more than 800 beds.
All 213 acute care facilities in the state were invited to participate in the survey, conducted from July to October 2011. Data are based on a 40% response rate.
A second survey was also e-mailed to nursing homes and skilled nursing facilities in the state to assess the scope of current and planned stewardship practices in those settings.
Dr. Abbo had no relevant financial disclosures. The survey was supported by a grant from the Florida Department of Health Bureau of Epidemiology.