{"id":2948,"date":"2019-09-09T08:30:35","date_gmt":"2019-09-09T13:30:35","guid":{"rendered":"https:\/\/blog.unmc.edu\/infectious-disease\/?p=2948"},"modified":"2019-09-05T16:24:41","modified_gmt":"2019-09-05T21:24:41","slug":"journal-club-stewardship-in-community-hospitals-how-should-we-spend-our-limited-resources","status":"publish","type":"post","link":"https:\/\/blog.unmc.edu\/infectious-disease\/2019\/09\/09\/journal-club-stewardship-in-community-hospitals-how-should-we-spend-our-limited-resources\/","title":{"rendered":"Journal Club – Stewardship in Community Hospitals: How should we spend our limited resources?\u00a0"},"content":{"rendered":"

Stewardship in Community Hospitals: How should we spend our limited resources?\u00a0<\/strong><\/h3>\n

\"\"The following is a review by our ID Fellowship Program Director\u00a0Dr. Trevor Van Schooneveld\u00a0<\/b>from our last Infection Control\/Antimicrobial Stewardship Journal Club. He discussed the article by Anderson et al:\u00a0Feasibility of Core Antimicrobial Stewardship Interventions in Community Hospitals. JAMA Network Open.\u00a0 2019;2(8):e199369<\/a>.\u00a0\u00a0<\/b><\/em><\/p>\n

Antimicrobial stewardship is important to improving patient care<\/strong> and outcomes and numerous entities recommend that hospitals implement an Antimicrobial Stewardship Program (ASP).\u00a0 Joint Commission requires ASPs in all settings and CMS is considering requiring all acute care facilities to have ASP.\u00a0 While ASP are common at large medical centers, smaller facilities including both community hospitals (CH) and critical access hospitals (CAH) are much less likely to have an active ASP.\u00a0 Additionally, the utility of strategies commonly employed in large facilities such as pre-authorization of antimicrobials (PA) and post-prescription review of antimicrobials (PPR) have not been evaluated in these smaller facilities who often lack ID trained personnel to support their program.<\/p>\n

Anderson and colleagues<\/strong> set out to evaluate the feasibility and impact of implementing these two common strategies (PA and PPR) in four community hospitals.\u00a0 They enrolled 4 moderately sized CH (median 305 beds) who did not previously have an ASP and trained at least one pharmacist at each location in appropriate antibiotic use and conflict resolution.\u00a0 They implemented PA at 2 facilities and PPR at the other 2 for 6 months with both strategies focusing only on use of vancomycin, piperacillin\/tazobactam (PT), and carbapenems.\u00a0 There was then a one month washout period followed by implementation of the alternative strategy.\u00a0 The local pharmacists has their stewardship time financially supported by the study site and received bimonthly feedback from the study center which has regional expertise in stewardship.\u00a0 Clinical guidelines were available to assist evaluation of antibiotic appropriateness.\u00a0 Local ID clinicians were only available routinely at one site and were not involved the ASP.<\/p>\n

The primary outcome was to determine if ASP implementation was feasible<\/strong> which it was in each facility.\u00a0 Although it should be noted that strict PA where an antibiotic is not distributed until approved was not feasible at any site and a modified PA was implemented where the first dose was distributed and then the appropriateness reviewed by local pharmacists.\u00a0 Both pharmacists and physicians were somewhat skeptical about the improvement to patient care in post-implementation surveys.\u00a0 While nearly 50% of clinicians said they didn\u2019t make any changes to antibiotics based on pharmacist recommendations over 30% admitted to choosing a non-study antibiotic to avoid a pharmacist call.\u00a0 The intervention was limited in scope as it only captured 30% of all study drug prescriptions.\u00a0 There were significant differences in the PA and PPR group with more antibiotics judged \u201cappropriate\u201d in the PA group and fewer interventions.\u00a0 The PPR group judged 41% of all study antibiotics inappropriate and intervened much more frequently, often with recommendations to de-escalate.\u00a0 Study antibiotic use did not significantly change although this was likely confounded by a PT shortage and increases in vancomycin use at all facilities the authors hypothesized was due to the introduction of the SEP-1 quality measures.\u00a0 Overall antibiotic use did not decrease during the PA portion but declined significantly with PPR.\u00a0 It should be noted that while statistically significant the decline represented a 5% decrease in use.<\/p>\n

What lessons can we take from this study?<\/strong><\/p>\n