The following post was written by Visante’s President, Hospital and Health System practice, James Stevenson as a response to the article “Rising threat of resistance highlights need for antimicrobial stewardship” published in the October 4, 2014 edition of Infection Disease News. The full article may be found using this link.
Antimicrobial stewardship programs (ASPs) have been shown to have benefits in managing the use of antimicrobial agents, slowing the development of resistance and reducing costs. Traditionally these programs have been organized under the pharmacy department, as much of the daily activities have been provided by clinical pharmacists. In addition, the programs have largely been justified through changes in antimicrobial utilization and an associated reduction in drug expenses. However, although many of the core activities of an ASP are being provided by pharmacists, the most effective structure is to have this program organized as part of the institution’s overall quality plan. Significant changes in drug utilization patterns are often only apparent for several years after implementation of an ASP, after which time the program focuses on maintaining the gains, as well as on more incremental improvements. This has led some institutions to question their ongoing value, only to see drug utilization and resistance patterns slide back after dismantling a program. The measures of effectiveness of an ASP should extend well beyond simple drug expense reductions and restrictions. An excellent program should focus on quality and outcome improvements in care. In fact, one might argue that having an ASP organized under the pharmacy department creates an internal conflict of interest in providing the best care to patients vs. care that is associated with the lowest drug expense. With the increased emphasis in the emerging health care system on quality, safety and outcomes data linked to reimbursement and public reporting, it is critical for the ASP to be an integral component of an institution’s overall quality program.
With the increase in clinical outcomes measures and performance metrics linked to outcomes, ASPs must evolve to demonstrate value through these broader measures. In addition to playing a key role in modifying resistance patterns and extending the usefulness of existing antimicrobial agents, ASPs can play a critical role in “bundles” with infection control and other strategies to reduce the rate of high-visibility conditions like catheter-associated urinary tract infections, central line-associated blood stream infections and Clostridium difficile infections, as well as reducing overall (not just antimicrobial) costs of care and readmission rates. Furthermore, studies have shown a positive impact of ASPs, coupled with rapid diagnostic testing, on reducing the time to effective therapy and on reducing mortality rates in patients with bloodstream infections. An effective ASP requires collaboration and teamwork by various health care providers including physicians, pharmacists, microbiologists, infection control practitioners, and health informaticists. Given the breadth of impact and collaboration required to successfully impact key quality and outcomes measures, it makes sense that the program receive oversight and monitoring at the institutional quality department level.