At Nebraska Medicine, our Antimicrobial Stewardship Program’s (ASP) clinical mission is to optimize the utilization of antimicrobial agents, thereby improving patient outcomes (by reducing the risk of adverse events and Clostridium difficile infection) and limiting the spread of antimicrobial resistance. These Antimicrobial Stewardship activities have been mandated by the Joint Commission and our program has been expanding its reach to include our satellite hospitals and our outpatient clinics to achieve this mission. Since a large majority of inappropriate antibiotic use occurs outside of the hospital, our outpatient initiatives are currently focused on education of clinic providers and patients on not using antibiotics for conditions that do not require them.
On the inpatient side, our stewardship activities have many impacts on patient safety. First, many studies have demonstrated the benefit of early Infectious Disease consultation for patients with Staphylococcus aureus bloodstream infection (SAB). When ID doctors are involved, patients are less likely to die or suffer complications, respond faster to therapy and will have fewer adverse effects. At Nebraska Medicine, we review approximately 150 SAB cases per year to prompt ID consultation. In addition, the discussion between the ASP reviewer and the primary team ensures the appropriate antibiotic is started immediately, even in advance of the ID consultation.
Last year, our ASP program documented over 2500 reviews of patients for appropriate antibiotic use, with 381 interventions to reduce antibiotic use by either discontinuing or de-escalating therapy, with a 90% acceptance rate of interventions. Not only did we assist with narrowing antibiotic use, 97 patients with untreated or resistant infections were identified and subsequently initiated on therapy as a result of ASP review, and nearly 200 ID consult requests were implemented in highly complex cases.
Furthermore, our ASP interventions have also resulted in reductions of vancomycin and piperacillin/tazobactam combination therapy when unnecessary. The combination of these two antibiotics has been shown to increase risk of kidney failure (which leads to worse clinical outcomes for patients), and the simple act of switching to alternative antibiotics to avoid this risk has tangible patient safety benefits.
In 2016, new initiatives were introduced to improve timing and redosing of antibiotic prophylaxis for surgery, in an effort to reduce the risk for surgical site infections (SSI). Coupled with the new SSI prophylaxis guidance, the program developed guidance on how to manage patients with beta-lactam allergies. This is important for patient safety because many patients receive 2nd or 3rd line antibiotics inappropriately in the context of remote penicillin allergies. Sometimes, like in the case of surgical prophylaxis, the data is clear that use of antibiotics other than cefazolin can lead to increased SSI risk. Providing evidence-based guidance in collaboration with our allergists empowers physicians to provide best care for their patients without perceived harm of allergic reactions.