Liise-anne Pirofski, MD: Antibiotic Stewardship: Changing the Culture
The following was adapted from the January 6, 2014 issue of the Montefiore Update e-mail newsletter.
Launched in 2008 at the Moses and Einstein Campuses and expanded to the Children’s Hospital at Montefiore (CHAM) in early 2013, the Montefiore-Einstein Antimicrobial Stewardship Program (ASP) was introduced last month at the Montefiore Wakefield Campus.
Antibiotics and similar drugs, known as antimicrobial agents, have been used for more than 70 years to treat patients with infectious diseases. When prescribed and taken correctly, their use improves patient care by expediting recovery time. However, because of their long and widespread use, many infectious organisms have adapted and become resistant, making the drugs less effective. People infected with antimicrobial-resistant organisms are more likely to have longer, more expensive hospital stays, and morbidity and mortality rates may increase, according to the Centers for Disease Control and Prevention (CDC).
Belinda E. Ostrowsky, MD, MPH
The ASP serves a vital function across Montefiore, taking an educational rather than punitive approach to advising clinician prescribers on the appropriate use of antibiotics. "This is an ongoing, multidisciplinary effort to create awareness of antibiotic resistance and the importance of appropriate antibiotic use," said Dr. Belinda Ostrowsky, Director, Montefiore-Einstein ASP and Associate Professor of Medicine (Infectious Diseases). Dr. Ostrowsky recently led a groundbreaking study finding that low doses of Vancomycin were as effective as high doses in treating serious infection in a hospital setting.
The ASP is highly collaborative and interdisciplinary, connecting physicians, surgeons, operating room nurses, pharmacists, infection control experts, microbiologists, epidemiologists and quality improvement staff. The program’s goal is to formulate a system-wide approach to aid clinicians in developing consistent treatment protocols in accordance with national guidelines, relying on medical literature, local data and clinical practices to inform its decisions. Education focuses on appropriate testing to diagnose infections, choosing the correct antibiotic regimen and knowing when to obtain consultation on infectious diseases.
Priya Nori, MD
Antibiotic preauthorization policies were enacted on December 1, 2013, specifying which antimicrobials require "antibiotic approval," or preauthorization by an antimicrobial steward, such as an Infectious-Diseases-certified physician or clinical pharmacist trained in infectious diseases (ID PharmD), regarding the appropriateness of the specified antimicrobial for each affected patient, according to Dr. Priya Nori, Director of the Montefiore-Einstein ASP at Wakefield, and Instructor of Medicine (Infectious Diseases).
To determine if the antimicrobial agent is suitable, clinicians and stewards discuss the infection itself, doses, durations of treatment and other critical care elements. "Often, we offer to facilitate an actual Infectious Disease (ID) consultation if the patient sounds particularly ill or if the illness is complex, especially since our phone discussions with providers cannot replace a clinical evaluation by an ID consultant," Dr. Nori said. "In the short time we have been in operation at Wakefield, we have found our discussions with providers to be very fruitful, engaging and educational. Providers are very grateful to have an additional infectious disease presence at Wakefield in the form of antimicrobial stewardship."
By restricting certain drugs as agents of last resort, the ASP has lowered spending on antibiotics by roughly $1 million between 2009 and 2011, according to Dr. Ostrowsky.
"We’re encouraged by the strong relationships we are building with providers at Wakefield and look forward to improving patient care through continued collaborative efforts," said Julie Williamson, PharmD, Clinical Pharmacy Manager at Montefiore.