Antimicrobial resistance is a growing, worldwide issue. According to the World Health Organization, a high percentage of hospital-acquired infections (HAIs) are caused by highly drug resistant bacteria that can result from inappropriate use of antimicrobial medicines.1
To address this issue, the Society for Healthcare Epidemiology of America (SHEA), the Infectious Diseases Society of America (IDSA), and the Pediatric Infectious Diseases Society of America (PIDS) issued a joint policy statement in 2007 recommending that clinicians improve antimicrobial stewardship through better coordination of interventions. The joint policy statement defines antimicrobial stewardship as “coordinated interventions designed to improve and measure the appropriate use of antimicrobial agents by promoting the selection of the optimal antimicrobial drug regimen including dosing, duration of therapy, and route of administration.”2
Antimicrobial management can be both a complicated and costly undertaking for hospitals and caregivers — yet is an ever-increasing necessity for delivering quality patient care. Traditionally, antimicrobial stewardship programs have relied on manual management methods, including clinical oversight and intervention to monitor and contain HAIs. As healthcare digitizes and incorporates electronic health records (EHR),clinical decision support (CDS) is becoming an essential componentfor antimicrobial stewardship programs. CDS can greatly help alleviate clinicians’ pain points in managing infectious diseases.
By automating the infection controlprocess, evidence-based CDS empowers clinicians to make the most informed treatment decisions at the pointofcareby providing real-time recommendations and a single dashboard view of all the patient population’s current conditions and medications. This enables clinicians to prioritize their schedules and treat the most critical patients first in order to manage and slow/stop the progression of infections.
The following are tools deployed in antimicrobial stewardship solutions that hospitals and caregivers should explore to help significantly reduce costly HAIs that can result from improper treatment of highly resistant bacteria.
De-escalation is a key component of antimicrobial stewardship programs. Physicians may prescribe antibiotics based on the hospital antibiograms. However, these antibiotics need to be de-escalated to either monotherapy or narrow spectrum antibiotics once the results of the culture and sensitivity are available.
One area where de-escalation is often practiced is in the treatment of ventilator associated pneumonia (VAP), where the most appropriate antibiotic selected can significantly improve the outcome. Organizations may choose to treat VAP based on the severity of the illness, antibiogram data, and then alter treatment once the culture and sensitivity reports become available. For example, patients who receive carbapenems may be de-escalated to pipercilin-tazobactam, and patients receiving pipercillin-tazobactam may be de-escalated to an antipseudomonal cephalosporin in presence of P. aeruginosa.3
De-escalation of antibiotic therapy is associated with a decreased incidence of multiple drug resistant organisms (MDROs). The intended outcome is to stop the progression of infectious disease, save lives, and reduce hospital length of stay, all while optimizing cost effectiveness resulting in potential significant savings.
IV to PO Conversion
Several studies document the direct impact of an aggressive and early IV to per os (PO) therapy conversion program. One study that specifically focuses on levofloxacin found proactive conversion to the oral formulation reduced patients’ length of stay by 3.5 days. In addition, the conversion saved approximately $60 in medication and supply costs and almost $3,300 in total hospital costs for each patient. Another recent study documented that early conversion from IV to PO therapy in community-acquired pneumonia decreased length of stay by almost two days, with no negative effects on mortality or clinical cure.4
The criteria used to determine whether or not the patient is eligible for PO therapy varies from facility to facility, but they generally encompass these three key areas:
- Conversion Eligibility Criteria
Patients on IV therapy for 48–72 hours, with a functioning GI tract, or showing signs and symptoms of clinical improvement (decrease in temperature, white blood cell count [WBC] <15,000/mm3), with the exception of those on steroids.
- Exclusion/Caution Criteria
Examples include patients with serious infections, like meningitis and sepsis, NPO status, or NG tube with continuous suction.
- Medication Class Criteria
Specific medications, such as antiepileptic and cardiovascular medications, as patients on these medications could be at higher risk when converted to PO therapy.
In order to optimize treatment, improve outcomes, and reduce associated costs, data needs to be effectively managed to improve awareness of the number of days that a patient has been on IV therapy for possible conversion to an appropriate PO medication.
Appropriate Antimicrobial Selection
An important feature of antimicrobial stewardship is properly managing data around culture and sensitivity reports along with antimicrobial/microbial mismatches. Each facility has its own protocols around appropriate drug specimen and drug dosage collaboration, so it is important to consider both industry guidelines, such as the Clinical and Laboratory Standards Institute (CLSI) M39 criteria, as well as facility-driven practices and trending.
Leveraging Existing CDS Technology
So, how do hospitals and physician groups address these treatment complexities of highly resistant and other bacteria?
The answer lies in more effectively harnessing the power of EHR and CDS technology that exists in many hospitals and physician offices today. IDSA and SHEA both recommend expanding the utilization of these technologies and the real-time patient data and treatment information they provide.They also suggest that integrating CDS technologies into EHRs would be beneficial for healthcare organizations.2
Infectious disease surveillance can be performed manually, but it is inefficient and time consuming. By implementing CDS technology, clinicians will be able to view patient information from a wide range of sourcesin existing HIS systems—health information exchanges (HIEs), EHRs, and portals—thus automating this process and freeing the clinical staff from much of the labor burden.
Additionally, CDS technology supports a facility’s antibiotic de-escalation processes by providing real-time recommendations and analytics dashboards to end users, notifying them of several important patient status updates such as:
- Culture and sensitivity results
- Number of days a patient has been on antimicrobial therapy
- Specific broad and narrow spectrum medications to administer per facility guidelines and practices
Real-time CDS and analytics technology can also provide recommendations and reports to increase awareness of the number of days that a patient has been on IV therapy for possible conversion to an appropriate PO medication. These real-time data queries are used to optimize treatment, improve outcomes, and reduce associated costs. In addition, they can also quickly identify patients with a multi-drug resistant organism (MDRO) who require isolation and can advise clinicians regarding appropriate isolation procedures based on the disease or condition of the patient.
With the need for infectious disease surveillance on the rise, automated reporting provides the capability to customize and automate reports as part of compliance with local and federal HAI reporting mandates. For example, The Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN) supports import of certain HAI data in clinical document architecture (CDA) format. Reports generated through automated CDA generation can cut down significantly on manual tasks that are arduous and error prone. Similar reports can also provide key information about individuals and entire populations of patients, such as diagnosis, disease, length of stay, key clinical indicators, pathogens, medications, safety parameters, and laboratory results.
CDS in Action
Real-time recommendations and population management enable the analysis of key data that is required for antimicrobial stewardship and, in turn, ensures patient safety while reducing unnecessary costs in several ways. These include the conversion of antibiotics to a narrower spectrum when appropriate, switching IV to PO, antimicrobial mismatching, and appropriate antimicrobial selection. By using CDS to automate infection control, monitor patients in real-time, better manage its inpatient population to decrease infection rates, and improve antimicrobial compliance with best practices, a 600-bed hospital can expect an annual savings of hundreds of thousands of dollars and possibly upwards of $1 million or more by effectively harnessing patient data and providing actionable information where and when it’s needed.
CDS in Your Practice
Practices that are manually handling clinical surveillance should keep in mind that Centers for Medicare and Medicaid Services (CMS) payments can be denied for not reporting on quality measures and HAIs, and exceeding readmission thresholds. In 2014, thiscan jeopardize up to eight percent of CMS payments.
If eight percent will dramatically impact an organization’s bottom line, implementing a CDS solution may be their best strategy for reducing chances of receiving CMS penalties. CDS provides a single view of patient data that delivers actionable information at the point of carein real-time–when it matters most–to directly and immediately help improve the quality of care for both individual patients and entire populations.
CMS guidelines will continue to include more CDS requirements in each stage of Meaningful Use core measures. Hospitals and physician practices should seriously consider implementing this vital tool for clinical surveillance to help reduce antimicrobial resistant bacterial infections around the world.
- Antimicrobial Stewardship for the Community Hospital: Practical Tools & Techniques for Implementation. January 10, 2012. Centers for Disease Control and Prevention (CDC), National Center for Emerging and Zoonotic Infectious Diseases (NCEZID), Division of Healthcare Quality Promotion (DHQP). At http://www.cdc.gov/getsmart/healthcare/learn-from-others/CME/antimicrobial-stewardship.html.
- Infection Control and Hospital Epidemiology. April 2012.Special Topic Issue: Antimicrobial Stewardship. Infectious Diseases Society of America (IDSA). 33;4:322–327. At http://cid.oxfordjournals.org/content/44/2/159.full#sec-19.
- J.Morel, J. Casoetto, R. Jospé, et al. 2010. De-escalation as part of a global strategy of empiric antibiotherapy management:a retrospective study in a medico-surgical intensive care unit. Critical Care, 14 (R225). doi:10.1186/cc9373.
- K. Kuper. 2008. Intravenous to Oral Therapy Conversion: Competence Assessment Tools for Health-System Pharmacies, Fourth Edition.
Dr. Fauzia Khan currently serves as CMO of Alere Analytics, formerly DiagnosisOne, where she provides direction and leadership to develop practical and scalable technologies that allow clinical decision support and analytic capabilities to be seamlessly incorporated into clinical workflows. She has expertise and passion for algorithm design, knowledge acquisition and engineering, as well as data mining and leveraging these capabilities to improve outcomes. Prior to forming DiagnosisOne, Dr. Khan was the director of informatics at UMass Memorial Medical Center with 10 years of experience in the hospital practicing pathology. She is the author, editor, and primary visionary of the “Guide to Diagnostic Medicine”, Lippincott Williams & Wilkins, 2002.