Experts Identify Key Ways to Strengthen Antibiotic Stewardship Programs

Reducing inappropriate antibiotic use in hospitals and other health care settings is essential to protect patients from alarming types of antibiotic-resistant bacteria, commonly known as superbugs. A new article in the Joint Commission Journal on Quality and Patient Safety outlines steps that hospitals can take to improve and better evaluate their antibiotic stewardship programs (ASPs), including two innovative interventions that go beyond the scope of typical programs.

The findings are the result of an expert convening last May organized by The Pew Charitable Trusts and The Joint Commission, a nonprofit organization that accredits and certifies health care organizations and programs in the United States. The American Hospital Association, the Centers for Disease Control and Prevention, and the National Quality Forum also took part in the process meant to encourage continuous improvement of hospital accreditation standards and best practices. This push comes as more facilities are implementing and expanding ASPs as part of efforts to reduce the number of antibiotic-resistant infections and to improve patient outcomes.

Emerging intervention strategies

At the conference, experts identified two approaches that complement, strengthen, or go beyond existing, widely used stewardship practices intended to ensure that antibiotics are used appropriately.

The first, referred to by several panelists as handshake stewardship, calls for a facility’s stewardship team to regularly engage with providers in-person about their antibiotic prescribing habits. The multidisciplinary team routinely reviews prescriptions by a given provider and provides face-to-face feedback. This creates a two-way flow of information that doctors and other providers do not get from traditional audit and feedback approaches. It also allows them to ask questions and give input on ways to continually improve the facility’s practice guidelines, creating a more collaborative working environment.

The second approach, referred to as diagnostic stewardship, focuses on ensuring that diagnostic tests are used appropriately. This intervention expands the scope of typical stewardship programs by working to reduce the number of unnecessary tests and minimize errors in patient diagnoses that lead to inappropriate antibiotic prescribing. For example, the use of diagnostic stewardship would limit unnecessary urine culture testing for patients without clear signs or symptoms of urinary tract infections, which should then reduce the incidence of inappropriate diagnoses and unnecessary antibiotic prescribing.

These emerging interventions have been implemented successfully in select hospital settings; however, more data are needed to understand how many already follow these practices, the applicability to different facility types, and possible barriers to implementation.

The importance of tried-and-true practices

Although the group was brought together to identify antibiotic stewardship practices beyond current requirements, many participants stressed the importance of the foundational characteristics of effective programs. Those include strong leadership, financial support, and community engagement and collaboration—both with area medical facilities that serve the same patient populations, such as long-term care facilities, and with academics.

Members emphasized the effectiveness of established stewardship practices, such as:

• Preauthorization, which requires providers to seek approval from the stewardship team before using certain antibiotics.
• Post-prescription reviews, through which an independent provider, not on the clinical team, reviews a patient’s antibiotics and gives input to the treating team.
• Adapting national guidelines for how antibiotics should be used to treat specific conditions, to incorporate local factors such as antibiotic resistance patterns.

Participants also identified key metrics for evaluating the success of antibiotic stewardship programs. These included measuring total antibiotic use at the facility level, duration of antibiotic therapy, rates of hospital-acquired C. difficile infections, and adherence to clinical practice guidelines, as well as prescribing patterns at the clinician level.

These findings now can inform improvements as organizations such as the CDC, The Joint Commission, and hospitals work to reduce inappropriate antibiotic use by strengthening stewardship practices.

David Hyun, M.D., works on The Pew Charitable Trusts’ antibiotic resistance project.