Antimicrobial Stewardship in Acute Care Settings

Antibiotics have been used since the 1960s and have been essential in the evolution of modern hospital care. Safe, effective, and relatively inexpensive, their use expanded markedly during the 1970s and 1980s when many “new and improved” antibiotics became available; they were convenient and had a broad range of uses. One new antibiotic, for example, often replaced two or three older ones.

As the use of antibiotics grew, so did antibiotic resistance, especially with regard to hospital-associated micro-organisms. This became increasingly worrisome to the health care sector. Coupled with budgetary pressures, antibiotic resistance prompted utilization reviews, which led to antimicrobial stewardship programs in some organizations. These programs are defined in the Accreditation Canada Required Organizational Practice (widely known as “ROP”) as:

“…an activity that includes appropriate selection, dosing, route, and duration of antimicrobial therapy. The primary focus of an antimicrobial stewardship program is to optimize the use of antimicrobials to achieve the best patient outcomes, reduce the risk of infections, reduce or stabilize levels of antibiotic resistance, and promote patient safety” (Accreditation Canada, 2013).

Most stewardship programs began in large, academic medical centres that had specialists in medical microbiology, infectious diseases, and clinical pharmacy. Programs often depended on the interests of local experts, were generally pharmacy-based, and were subject to the competitive pressures of rising expenses in all drug classes. Very little acute care antimicrobial stewardship occurred outside these centres.

In the mid-1990s, the Canadian Infectious Disease Society and Health Canada co-sponsored a two-day conference called “Controlling Antimicrobial Resistance: An Integrated Action Plan for Canadians.” Experts and policy makers came together and made numerous recommendations including the establishment of “…antibiotic stewardship and antibiotic use teams in all Canadian hospitals by incorporating them into accreditation standards.” Unfortunately, very little happened after that for a number of years.

Then, in 2005, a seminal report was published by Dr. Jacques Pépin, describing a large increase in the incidence and severity of Clostridium difficile (C. difficile) in Quebec. The report claimed that C.difficile was responsible for an estimated 2,000 deaths, a claim that quickly put hospital infections in the public and political spotlight. C. difficile and Severe Acute Respiratory Syndrome (SARS) had exposed serious shortcomings in infection prevention and control(IPC) in hospitals, and the response was swift. Investments in IPC were made across Canada—infrastructure was improved, more IPC personnel were hired, and some decreases in the rates of hospital-acquired infections were noted. Antibiotic stewardship was recognized as an appropriate response to C. difficile but there were few changes outside Quebec.

The quality and safety movement

The Canadian Patient Safety Institute was established in 2003 as a federal response to the increasing focus on patient safety. Since that time, there has been a slow and steady increase in provincial and acute care infrastructure to promote safety practices. Most jurisdictions have established health quality councils or undertaken a similar initiative within government. It is vital that central structures (e.g., health authorities, provincial governments) and experts actively support the administrative functions, such as policy and priority setting, of antimicrobial stewardship programs.

Many new and robust IPC programs were created under quality and safety portfolios and their creation helped move quality and safety agendas forward. Accreditation Canada, for example, as an independent, third-party organization, markedly increased the IPC requirements in its standards to support quality improvement.

Human resources

Who then is integral to these antimicrobial stewardship portfolios? Clinical pharmacists are the backbone of acute care infrastructure. Much of the day-to-day delivery of antimicrobial stewardship programs is performed by clinical pharmacists with guidance from senior clinical pharmacists and physicians. Clinical pharmacy programs are generally well established in academic health science centres and less so in smaller health care centres because antimicrobial stewardship often has to compete against other clinical pharmacy services for resources. Quantifying a need and establishing stable funding for clinical pharmacists is an essential step in establishing antimicrobial stewardship programs.

Physicians are integral to antimicrobial stewardship programs. A local champion with specific medical knowledge can help develop and maintain these programs. Yet, most infection specialists (infectious disease specialists, medical microbiologists) work in large centres; it will be important to find ways to interest local clinicians in working on programs at smaller centres.

It will also be necessary to reconsider medical human resources as they relate to consultation and expert guidance in case management. The use of remote technology for consultation will facilitate the expansion of antimicrobial stewardship programs into more remote communities. Because of the concentration of medical expertise in large, urban centres, and the size of Canada, it will be important to develop region-specific solutions that will likely involve remote technology to support human resources.

Information technology and data collection

Two types of information are essential to antimicrobial stewardship—antimicrobial use and antimicrobial susceptibility (i.e., laboratory testing of the effectiveness of an antimicrobial agent). Most Canadian institutions do not have well-developed systems to meet these data needs. Some of this is happening as facilities are modernized and upgraded, but it is essential that the needs of antimicrobial stewardship programs be considered during laboratory or pharmacy technology upgrading efforts.

The development of provincial data collation and interpretation centres could also play a role in supporting standardized measurement of success and areas that need improvement.

Quality and safety—the connection with IPC

Administrative support for antimicrobial stewardship falls naturally within the quality and safety portfolios, and these are clearly aligned with IPC. Synergy among IPC programs can be realized quickly, as many physician champions are involved in both IPC and antimicrobial stewardship. Of course, the microbiology laboratory is also an essential partner.

Some international programs have been moving toward infection management teams, with more integration of infection prevention, diagnosis, and therapy. This may be the next logical step in Canada.

A Scottish model

The Scottish Antimicrobial Prescribing Group (SAPG) (http://www.scottishmedicines.org.uk/SAPG/Scottish_ Antimicrobial_Prescribing_Group__SAPG) was created to facilitate implementation of a 2008 action plan on antimicrobial resistance. Numerous lessons can be learned from its success (http://www.aricjournal.com/content/1/1/7), as there are similarities between the Canadian and Scottish medical services delivery models. One of the primary lessons is that dedicated funding is essential—new money was identified to create the SAPG infrastructure and to fund clinical pharmacists on all of the regional boards. The same type of investment is required in Canada.

Conclusion

In the past decade, quality and safety portfolios have become increasingly important in Canadian health care organizations, better positioning Canada to tackle the difficult challenge of managing antibiotic resistance using antimicrobial stewardship programs. With serious attention and investment, antimicrobial resistance is manageable.

The perils of pet rats

A girl plays with Paddington the rat at the Royal Easter Show in Sydney, Australia. Picture: Justin Lloyd Source: Herald Sun

In my 18 months of taking my turn overseeing the Vancouver Island Health Authority diagnostic microbiology laboratory I have been involved in the diagnosis of 3 cases of Streptobacillus moniliformis infection.

All three were quite serious requiring several days of hospital care. All three involved pet rats. At least 2 of them were not associated with a bite but were associated with very intimate “face to face” contact with the rat. I believe there have been four more cases within the last 3 years diagnosed in our lab. Seven cases in one small city in three years associated with pet rats without bites.

Rat bite fever is a serious infection that can be fatal. All rats have S. moniliformis in their mouths. All rat owners are at risk. It is clear that close contact without a bite can transmit this infection. It seems reasonable that an attempt be made to inform rat buyers of the risk and that there is a role for public health.

Likewise physicians need to be aware of the possibility and ask febrile patients specifically about rat contact.

The most recent case is summarized here Rat Bite Fever

Stewardship is Structure

Certainly in the Canadian context, Antimicrobial Stewardship is a public service.

public service noun

  1. : the business of supplying a commodity (as electricity or gas) or service (as transportation) to any or all members of a community
  2. : a service rendered in the public interest

It fulfills both of these dictionary definitions perfectly. Stewardship programs provide a service to members of communities — The community of healthcare providers to aid in their provision of care and to the community at large to provide the ongoing benefits of the availability of effective antimicrobials. This is very much in the public interest.

More established public services such as the police, fire fighting and waste removal are easy to conceptualize and understand. Others such as fisheries and forest management are more difficult. Few would dispute that the management of common resources is important, however. Common to all are several elements.

Information
Could the Department of Fisheries perform its’ functions without information? Of course not. Just as information about fish stocks is necessary to define sustainable fish harvest quotas, information is necessary to manage antibiotics. Fortunately, much of the information needed to manage antibiotic use is readily available. Millions of susceptibility tests are performed and all antibiotics distributed for human use are under prescription and have records associated. We haven’t yet done a good job of collation, redistribution and display but it is only a small amount of idea and resource away.

Manpower
Nothing ever prospers as a “side of the desk” endeavour. Why would Antimicrobial Stewardship be any different? It needs dedicated thoughtful people with appropriate skill sets – just like anything else. The good news is that evaluations of established AS programs have shown cost savings even after taking account the increased expenditures on manpower. Antimicrobials have been so poorly managed that there is much wasted resource. There is a large potential to turn misused antimicrobials into excellent, well-paid, stable jobs for Canadians.

Policies and Procedures
Policies are informed by principles and guide procedures. Goal statements and metrics for evaluation are central. Nothing unusual about this. However, this is new in Canada and much trial and error is to be expected. The principles should be firmly established but procedures will necessarily be diverse as Canadian health delivery is diverse.

Education
The cornerstone of sustainability. All established conservation programs become easier to enact as the benefits are recognized by more and more people. They become the norm.

Canada is poised for a Antimicrobial Stewardship revolution. We have the enthusiasm, the people and the need. We just need some structure.

A new look

InfectionNet has a new look and hopefully some new followers.

After a reasonably long and patient courtship with Drupal, we have cast it aside in favour of WordPress. Terry (the web design master) and I think infectionNet scrubs up quite well with her new content management software. There is a bit of tweaking yet to do so don’t fret over a bit of messed up formatting.

The elements are all still there – articles, notes from medical school lectures and laboratory protocols and I have added some important new sections. Therapy guidelines are derived from the Vancouver Island Health Authority’s Antimicrobial Review Committee’s empiric guidelines that were produced during a recent collaborative antibiotic stewardship effort at Cowichan District Hospital.

The Discussions section has been revamped and, hopefully, is a more user-friendly way of finding answers to your questions and to interact with peers. It is now easy to sign up with your Facebook or Google IDs and have your say.

The Cases section is very lean on content at present but there are plenty of interesting cases and they need display. Keep checking back, or better yet tell me about yours.

Be sure to sign up for email updates, and follow us on twitter as infectionNet is going to be much more proactive and interactive. If you have any suggestions at all please let me know using the contact form.

National pharmacare for antimicrobials

Canada is a patchwork of private – public coverage for pharmaceuticals. All provinces have pharmacare plans but they vary widely in coverage. Saskatchewan and Manitoba have forms of universal coverage while other provinces cover specific groups such as those on social services and the elderly.

In 2005 the first ministers conference saw a plea for a national pharmacare plan endorsed by all premiers. It was widely discredited as a provincial grab for federal money as a response to pharmaceuticals being the most rapidly expanding sector of healthcare expenditure. It was scoffed at by the federal government and deemed to be “too expensive” for consideration. This despite overwhelming evidence that the buying power and reduced bureaucracy afforded by cooperation would result in significant savings.

How about just antimicrobials? The federal expense would not be prohibitive. Outpatient antimicrobials total less than a billion dollars annually. It could lay the groundwork for future expansion to other classes and most importantly it would distinguish antimicrobials as needing special regulatory attention.

A National Antimicrobial Pharmacare plan is a sensible approach to the ever-expanding problem of antimicrobial resistance.

Stewardship is the word

I have been involved in the effort to improve antibiotic policy and practice for many years and a recent development may be a large help. Rather than advocating for prudence we are now recommending stewardship. Prudence – classically considered a virtue, in particular one of the four Cardinal virtues, conjures up the notion of morality. One who prescribes antibiotics poorly is immoral.

Stewardship is entirely different. It is an ethic that embodies cooperative planning and management of resources and conjures the notion of help and guidance. One who prescribes antibiotics poorly needs guidance.

I think this subtle shift in the language of antibiotic policy may help us immensely. Rather than demanding prudent use regulations that imply the stamping out of immorality we can offer frameworks for regulatory bodies to cooperatively guide prescribers. That guidance may necessarily have to include restrictive policies but with the restrictions arrived at in a more consensual fashion.

If you are interested in Antimicrobial Stewardship check out the International Society of Chemotherapy’s new Inventory of Antimicrobial Stewardship projects.

Stewardship with effect – The 4 C’s

This graph depicts the change in percentage of antibiotics belonging to the 4C group – clindamycin, cephalosporins, co-amoxiclav, and ciprofloxacin (fluoroquinolones) in Grampian, Scotland NHS acute care hospitals. There is a strong association with reductions in C. difficile incidence.

This graph show the changes in the individual classes of 4 C’s. Very impressive reductions demonstrating the power of organized stewardship efforts.

Thanks to Dr. Ian Gould for sharing this. This project was specifically designed to reduce the incidence of C. difficile by reducing the use of antibiotics most associated with C. difficile disease. Read more about The 4 C’s Project here at the International Society for Chemotherapy’s World Inventory of Antimicrobial Stewardship site.

It appears that Scotland is making great strides in organized antimicrobial stewardship having established a country-wide multidisciplinary forum in 2008 referred to as the Scottish Antimicrobial Prescribing Group (SAPG). Read more about their efforts here at the SAPG website.

An example of good, well-displayed information being well received

Problem
Protocols for microbiology laboratory technologists were hard to access. Paper manuals were hard to locate. “Cheat sheets” were not uniform and had been edited in an ad hoc fashion. Senior technologists offered differing opinions to junior technologists.

Solution
InfectionNet/Lab. Modern, web-based, well-displayed information accessible to all. One version. Controlled creation and editing. Easily enhanced.

In two short months this means of creating and displaying microbiology laboratory protocol information has been not only accepted but very actively embraced by Eastern Health laboratory staff. They have discussed, suggested improvements, and taken steps to assuming ownership of the content.

Good design effecting positive change – excellent.

Antibiotic resistant gonorrhea – another reason for antibiotic regulation

An excellent paper and accompanying editorial in the Canadian Medical Association Journal describes huge increases in fluoroquinolone antibiotic resistance in Ontario from 2002 to 2006. Similar changes have been described in many other parts of the world.

Fluoroquinolones have only been in existence since the 1980s and first licensed for sale in Canada in 1988. They were the first new class of antibiotic introduced for many years and were received with extreme expectations. They were widely touted as the solution to antibiotic resistance to penicillins, tetracyclines, sulfa antibiotics and others. Ciprofloxacin, the most successful of the class was brilliantly marketed to community-based physicians as having “IV power in an oral formulation”.

In 20 short years one might say “the arse has well and truly fallen out of ‘er”. Fluoroquinolones are all but useless for many clinical indications. 20 years! All over the world!

Another good reason to increase attention to antibiotic misuse and develop the regulatory structures needed to tackle this urgent and relentless problem.