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30 Clinical
Pharmacy Practice News • November 2020
Infectious Disease
Part 1 of a 2-part series
ABx Stewardship Spreads Its Wings A
ntimicrobial stewardship programs are on the rise. What started as an effort to improve antibiotic prescribing and reduce antibiotic resistance in inpatient settings has been gradually expanding to ambulatory care, emergency departments (EDs), and even some settings outside of traditional health systems. “We’ve seen, in the last 10 years, tremendous growth in antimicrobial stewardship programs,” said Anna Legreid Dopp, PharmD, the senior director of clinical guidelines and quality improvement at ASHP. In a 2018 ASHP survey, about 45% of responding hospitals said they had antimicrobial stewardship programs, she noted. That number today is over 90%. In addition, the survey suggests there are opportunities for antimicrobial stewardship practices to extend beyond hospitals, into ambulatory settings. This includes 90% of responding larger hospitals with more than 600 beds, and 30% of smaller hospitals. “We know that close to 30% of antibiotics used in outpatient settings are prescribed unnecessarily, so there’s definitely a huge need for it,” Dopp said. Stewardship is being evaluated in many areas, said Susan Davis, PharmD, the president-elect of the Society of Infectious Diseases Pharmacists and a professor of pharmacy practice at Wayne State University, in Detroit. Pharmacists are recognizing that although the broad-spectrum antibiotics might be used in hospitalized patients, the bulk of antibiotics are used outside of the hospital. “That means inpatient stewardship experts are having to learn practice models they haven’t previously been involved in, so partnering with pharmacists in community and ambulatory care settings is really essential,” Davis said. One ongoing project at her health system involves working with primary care and urgent care clinics to offer symptom relief gift bags to patients
218 The number of interventions clinical pharmacists made on daily rounds to optimize antimicrobials.
26 The number of recommendations made to optimize anticoagulation.
20 Patients educated at discharge about their high-risk medications.
100% Of interdisciplinary clinicians strongly agreed that a pharmacist should continue on the ABx stewardship care team.
presenting with common respiratory illnesses—such as sinusitis, bronchitis or sore throat—who don’t need antibiotics. Borrowing an idea posted on Choosing Wisely by Mayo Regional Hospital in Maine, the Detroit pharmacists developed a symptom relief guide for patients, naming over-the-counter products to address their symptoms. They also put together bags containing items such as saline nasal spray, tissues, lip balm and sugar-free cough drops, as well as a card referring them to an outpatient pharmacy within the health system, where pharmacists help patients choose products that may provide relief. “It’s really hard to send someone home and say, ‘Sorry, we can’t do anything for you,’” she said. “That’s the last thing a clinician wants to do.” Davis and her colleagues tracked results during the first year of the program and got “some great uptake,” especially in downtown hospitals. Some 500 gift bags were distributed in five walk-in clinics in 2018, with half of pharmacy vouchers redeemed for over-the-counter products. From there, the team received a grant from the Michigan Pharmacists Foundation to provide 650 bags in nine clinics in 2019. “It’s something that our pharmacists feel excited to do,” she said.
At Duke, EDs a New Focus Outpatient, urgent care and EDs are another area of growth for antimicrobial stewardship programs. Rebekah Wrenn, PharmD, an infectious diseases clinical pharmacist at Duke University Hospital, in Durham, N.C., and her colleagues have been tackling antibiotic prescribing for urinary tract infections (UTIs) in the ED. About 13.7 million antibiotic prescriptions are written by emergency physicians nationally, and about half of outpatient antibiotic prescriptions are expected to be inappropriate, said Wrenn, citing 2017 CDC data (bit.ly/ 30DNbBG) Her team is focusing on socalled “treat-and-release” patients who present to the ED but are not admitted. “Patients are seen briefly, and clinicians don’t have a lot of data when making antibiotic decisions,” she said. “We felt clinicians really needed tools to help treat patients appropriately that fit into the workflow of the ED, which is quite different than inpatient treatment.” In a pilot project at three hospitals in the Duke University Health System (DUHS), Wrenn and her colleagues created a UTI antibiogram based on outcomes from treat-and-release patients at the institutions, as well as current treatment guidelines. They also conducted in-person education sessions
At Duke University Hospital, in Durham, N.C., the antimicrobial stewardship and evaluation team (aset) created pocket cards (left) on appropriate antibiotic prescribing and placed the cards at workstations. The cards are part of Duke CustomID, a decision support tool intended to provide clinicians with institution-specific, accessible, easily customizable information about the diagnosis and treatment of infectious diseases.
for resident physicians on appropriate prescribing and made recordings of those sessions available for attending providers. A pocket card on appropriate antibiotic prescribing was placed at workstations and added to a centralized tool, Duke CustomID. The team has provided feedback on how the ED providers are doing with guidelines concordance on a monthly basis; that is being expanded to look at individual provider performance. A poster about the work, presented at IDWeek (No. 45), showed that these interventions improved DUHS’s guidelines concordance in the first six months of the project, from 31% to 39% at one hospital, from 48% to 49% at a second hospital, and from 48% to 60% at the third hospital. Further studies will tease out how to continue these improvements. The goal is not to get to 100% guidelines concordance, Wrenn noted. For example, there will be cases in which patients have prior cultures indicating they need a different antibiotic or have adverse reactions to the guidelines-recommended treatment. Wrenn’s team also is sampling some cases in which providers didn’t follow the guidance and doing a deep chart review to identify why.
PeaceHealth Southwest Keeps Stewardship in the Family UTIs also were the focus of a pharmacist-led ambulatory antimicrobial stewardship program in a family medicine clinic at PeaceHealth Southwest Medical Center, in Vancouver, Wash. There, a combination of in-person education for clinicians, a guidelines-based antibiotic treatment summary made available in the electronic health record (EHR), and treatment defaults in the electronic order sets nearly doubled guidelines-based treatment adherence for uncomplicated cystitis and pyelonephritis (J Clin Pharm Ther 2020 Jul 24. [Epub ahead of print]. doi: 10.1111/jcpt.13210). In 2018, before
the intervention, 37% of patients were given the proper antibiotics at the appropriate dose and duration; that increased to 71.6% after the intervention (P<0.001). Although it can be helpful to have stewardship teams in the background making changes to the EHR, the work gains traction in the live education and training of residents and clinicians, noted study co-author and clinical pharmacist Luke Vander Weide, PharmD. Clinics that have resident physicians who turn over annually can benefit from periodic reeducation about proper antibiotic selection, added study co-author and clinical pharmacist Julia McCormick, PharmD.
Johns Hopkins Bayview Reaches Into Underserved Departments Pharmacists also can make a difference extending stewardship to previously untapped areas of the hospital. Johns Hopkins Bayview Medical Center, in Baltimore, did not have a clinical pharmacist dedicated to general and orthopedic surgery. Because pharmacy staff received a lot of clinical questions from this area, they wanted to see what would happen if a pharmacist was assigned to the units, said Farrah Tavakoli, PharmD, formerly with the medical center and now a formulary management pharmacist with the University of Maryland Medical System. In just a two-week period, the clinical pharmacist attended daily multidisciplinary rounds and made 218 interventions, including 38 recommendations to optimize antimicrobials, 26 recommendations to optimize anticoagulation, and provided education for 20 patients who were discharged on high-risk medications (J Pharm Pract 2020 Jul 21. doi. org/10.1177/0897190020938196). In an anonymous survey of multidisciplinary staff on these floors, 100% of respondents strongly agreed that a clinical pharmacist should be part of the team.
