Antibiotic Stewardship – A Results-Oriented Approach
2016 Best Practice Implementation Award Winner
by Peter P. Patterson, MD, MBA
Patterson LTC Consults

The uncomfortable truth at the root cause of antibiotic resistance is the huge numbers of people receiving antibiotics for infections they do not actually have.  A ready example is the persistent widespread practice of prescribing antibiotics for asymptomatic bacteriuria. However the problem is actually much larger if an audit is conducted of actual prescribing practices in any given skilled facility.

An innovative stewardship protocol has been achieving significant early results in a pilot program begun in 2015. The protocol won a best-practice award at CALTCM 2016 in April. The protocol is aimed directly at altering:

1.     Prescribing habits that sustain the root cause of resistance.
2.     Thinking and practices of nurses – a major driver of antibiotic overuse.

The protocol has two major components:  audit-feedback using data from surveillance of facility prescribing practices and a communication plan specifically designed to facilitate getting the message out to prescribers (physicians and nurse-practitioners). The leadership of the facility medical director is key to turning surveillance findings into alterations in practice.

A unique feature of the surveillance audit is a focus on the whole syndrome of UTI prescribing which often begins with a urinalysis and culture. Syndromic surveillance here combines culture data from the laboratory with related pharmacy and clinical data to produce a clear picture of actual prescribing practices in a skilled facility. The laboratory data answers the question ‘how many urine cultures were done’ and the details of positive cultures. From related pharmacy data it can be determined how many patients with positive urine cultures were treated with antibiotics. From related clinical chart data it can be determined how many of the treated patients met a standard definition of infection – fulfilled McGeer criteria for UTI. These data from three separate sources are collected by the infection preventionist on a single surveillance sheet every month and a summary is reported to the QA Committee every quarter.

The quarterly summary reports are simple one-page documents. An example is shown in Figure 1A. The report shows nearly half of patients in this facility receiving antibiotics for UTI have low colony counts. Culture results with low colony counts (25-50,000 cfu/ml) when reported with an organism name and susceptibility report are frequently misinterpreted as indicating a need for antibiotic treatment. Such results are much more likely to represent normal resident microbiome than infection. A copy of the quarterly report is sent to all facility prescribers with a cover memo from the facility medical director. The cover memo underlines the findings and sets a clinical action goal for the coming quarter. Results of the protocol’s audit-feedback is reflected in Figure 1B which shows the gradual disappearance of the practice of treating low colony counts over the next 2 quarters as prescribers see their practice in relation to their peers and professional guidelines.

Figure 1A

Figure 1B

A key step in the start-up sequence for the stewardship protocol is comprehensive in-service training for prescribers and nurses. Key components of the in-service are:

1.     The root cause of antibiotic resistance.
2.     Clinically-relevant microbiology – short course.
3.     Standard definition of UTI – McGeer criteria.
4.     UTI SBAR – talking to prescribers.
5.     48-hour observation pathway.
6.     Antibiotic Rx is in transition:
From:  Just-in-case      To:  Just-in-time

 

The 48-hour observation pathway (#5 above) is an approach to managing clinical uncertainty in low-likelihood scenarios – for example confusion with no systemic or localizing signs to the urinary tract. In these situations active observation is preferable to starting an antibiotic just-in-case. Most of these will resolve with pushing fluids and observation for change-of-condition.

Antibiotic resistance is now one of the most urgent public health issues. The stewardship protocol described here has been shown to substantially eliminate unnecessary urine cultures, outdated prescribing practices and the burden of antibiotic complications – see Figure 2. These begin to disappear once a facility gets its arms around the overuse of antibiotics by facing inconvenient truths and going to work directly at the root cause.  A big transition is underway in antibiotic prescribing – away from using antibiotics just-in-case – toward only using antibiotics just-in-time. Each of us has an important part to play in preserving the effectiveness of antibiotics for all our patients. 

Figure 2
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