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Antimicrobial Stewardship: A Collaborative Partnership between Infection Preventionists and Healthcare Epidemiologists

Julia Moody MS SM(ASCP), Sara E. Cosgrove MD MS, Russell Olmsted MPH CIC, Edward Septimus MD FACP FIDSA FSHEA, Kathy Aureden MS MT(ASCP)SI CIC, Shannon Oriola BSN RN CIC COHN, Gita Wasan Patel RPh PharmD BCPS and Kavita K. Trivedi MD
Infection Control and Hospital Epidemiology
Vol. 33, No. 4, Special Topic Issue: Antimicrobial Stewardship (April 2012), pp. 328-330
DOI: 10.1086/665037
Stable URL: http://www.jstor.org/stable/10.1086/665037
Page Count: 3
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APIC/SHEA Position Paper

Antimicrobial Stewardship: A Collaborative Partnership between Infection Preventionists and Healthcare Epidemiologists

Julia Moody, MS, SM(ASCP),1
Sara E. Cosgrove, MD, MS,2
Russell Olmsted, MPH, CIC,3
Edward Septimus, MD, FACP, FIDSA, FSHEA,4
Kathy Aureden, MS, MT (ASCP)SI, CIC,5
Shannon Oriola, BSN, RN, CIC, COHN,6
Gita Wasan Patel, RPh, PharmD, BCPS,7 and
Kavita K. Trivedi, MD8
1. Workgroup Chair; HCA, Inc., Nashville, Tennessee
2. SHEA Advisor; Johns Hopkins Medical Institutions, Baltimore, Maryland
3. 2011 APIC President; Trinity Health, Ann Arbor, Michigan
4. SHEA Advisor; HCA, Inc., Nashville, Tennessee
5. Sherman Hospital, Elgin, Illinois
6. Sharp Metropolitan Medical Center, San Diego, California
7. HCA Supply Chain Services, Dallas, Texas
8. Center for Health Care Quality, California Department of Public Health
    Address correspondence to Julia Moody, MS, SM(ASCP), Clinical Director, Infection Prevention, Workgroup Chair, Clinical Services Group, HCA, Inc., Nashville, TN 37203 ().

Misuse and overuse of antimicrobials, primarily involving therapeutic agents used to treat infection in humans, is considered one of the world’s most pressing public health problems.1 Not only does such inappropriate use diminish the therapeutic benefit of essential medications, it also facilitates the development and spread of multidrug-resistant organisms (MDROs).2 Antimicrobial resistance and the rise in MDROs globally are associated with increased morbidity and mortality, cross-transmission within and between healthcare settings, and increased consumption of limited patient-care resources. Despite elevated awareness, publication of guidelines on antimicrobial stewardship,3 and several initiatives, the proportion of resistant strains causing both health care– and community-associated infections continues to increase and the number of new antimicrobials continues to decline.4,5

In response to this growing problem, the Centers for Disease Control and Prevention (CDC) launched the Get Smart for Healthcare initiative6,7 in 2004, which includes a national campaign to promote collaboration across healthcare settings and mobilize national and local health officials in educating patients, consumers, and healthcare practitioners about appropriate use of antibiotics. The importance of antimicrobial resistance was recently highlighted by the World Health Organization (WHO), which dedicated World Health Day 20118 to halting the spread of antimicrobial resistance. The CDC and WHO are leading voices working toward an international solution with a three-pronged focus: (1) optimizing use of existing antimicrobial agents, (2) preventing transmission of MDROs, and (3) pursuing new therapeutic tools to treat emerging pathogens.

Antimicrobial Stewardship (AS) is an interprofessional effort and involves optimal, prudent antimicrobial use for patients across the continuum of care: acute, inpatient, and long-term care and outpatient settings.9

This position paper highlights the critical importance of healthcare epidemiologists (HEs) and infection preventionists (IPs) in effective antimicrobial stewardship programs (ASPs). The skills and knowledge each of these highly skilled professionals brings to a facility’s ASP, when combined with other disciplines, can accelerate progress toward preventing emergence and cross-transmission of MDROs (Table 1). The Association for Professionals in Infection Control and Epidemiology (APIC) and the Society for Healthcare Epidemiology (SHEA) are the professional organizations with historical focus, expertise, and credibility in articulating and implementing best practices in antimicrobial stewardship and infection prevention and control.

Table 1. 
Examples of Healthcare Epidemiologist (HE) and Infection Preventionist (IP) Strategies to Improve Stewardship
• Identification of MDROs detected among the population served by a healthcare facility
• As part of surveillance, the monitoring and reporting of trends over time involving multidrug-resistant organisms
• Oversight of the use of standard and transmission-based precautions aimed at preventing cross-transmission of pathogens
• Compliance with hand hygiene
• Use of surveillance data to inform risk assessment and planning for prevention of infection
• Education of clinicians on prudent and appropriate use of antibiotics
• Development of clinical algorithms for treating infections
• Audit, analysis, and reporting of data on healthcare-associated infections
• Implementation of strategies aimed at prevention of infection and elements involving prescribing and therapeutic use of antimicrobials (eg, guidelines, decision support involving order/entry, de-escalation)

APIC and SHEA believe the following:

  • MDROs cause a significant proportion of serious healthcare-associated infections (HAIs) and pose significant risk to patient safety across all points of health care delivery.

  • Regulatory and accreditation organizations, along with legislative bodies, must continue to make HAIs, including those caused by MDROs, a greater priority in health care.10,11

  • Integrated, multidisciplinary ASPs led by a physician and a pharmacist with training in antimicrobial stewardship are crucial to promoting the prudent use of antimicrobials and in combating the development of MDROs in all health care settings.

  • ASPs can benefit infection prevention and control (IPC) programs by identifying reported trends and outbreaks of epidemiologically significant organisms and educating about infection prevention policies in the course of interaction with providers.

  • IPs and HEs benefit ASPs by providing support and guidance in approaches to surveillance for syndromes of interest, implementing interventions to guide the delivery of evidence-based practices, and translating data and infection rates to healthcare workers, nursing units, and administrators.12-14

Summary

It is clear that the widespread and injudicious use of antimicrobials has greatly increased the presence of MDROs that threaten the health of all. There is worldwide acknowledgment that this threat is growing and that prudent use of antimicrobials combined with infection prevention can prevent harm and improve patient safety. ASPs must harness the talents of all members of the healthcare team to effectively identify the organism, determine its susceptibility, institute any precautions required, and prescribe the narrowest-acting antibiotic that will destroy it. IPs/HEs play a pivotal role in this approach by assisting with early organism and infected-patient identification, by promoting compliance with standard and transmission-based precautions and other infection prevention strategies such as care bundle practices, hand hygiene, and by educating staff, patients, and visitors.

Acknowledgments

We acknowledge Arjun Srinivasan, MD, FSHEA, for his insightful review and commentary.

Potential conflicts of interest. All authors report no conflicts of interest relevant to this article.

References

  1. 1. Bartlett JG. A call to arms: the imperative for antimicrobial stewardship. Clin Infect Dis 2011;53(suppl 1):S4–S7.
  2. 2. Cuzon G, Naas T, Truong HV, et al. Worldwide diversity of Klebsiella pneumoniae that produce β-lactamase blaKPC-2 gene. Emerg Infect Dis 2010;16:9.
  3. 3. Dellit TH, Owens RC, McGowan JE Jr, et al. Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clin Infect Dis 2007;44:159–177.
  4. 4. Hidron AI, Edwards JR, Patel J, et al. National Healthcare Safety Network Team. NHSN annual update: antimicrobial-resistant pathogens associated with healthcare-associated infections: annual summary of data reported to the National Healthcare Safety Network at the Centers for Disease Control and Prevention, 2006–2007. Infect Control Hosp Epidemiol 2008;29:996–1011.
  5. 5. Kumarasamy KK, Toleman MA, Walsh TR, et al. Emergence of a new antibiotic resistance mechanism in India, Pakistan, and the UK: a molecular, biological, and epidemiological study. Lancet Infect Dis 2010;10:597–602.
  6. 6. Centers for Disease Control and Prevention. Get Smart: Know When Antibiotics Work. Get Smart Web site. http://www.cdc.gov/getsmart/. Accessed November 23, 2011.
  7. 7. Centers for Disease Control and Prevention. Get Smart for Healthcare. Get Smart Web site. http://www.cdc.gov/getsmart/healthcare/?s_cid=dhqp_002. Accessed November 23, 2011.
  8. 8. World Health Organization (WHO). World Health Day: 7 April 2011. Antimicrobial Resistance: No Action Today, No Cure Tomorrow. World Health Organization Web site. http://www.who.int/world-health-day/2011/en/index.html. Accessed November 23, 2011.
  9. 9. Fishman N. Antimicrobial stewardship. Am J Infect Control 2006;34(suppl):S55–S63.
  10. 10. The Joint Commission (TJC). Assets for Acute Care Hospital Accreditation 2011: Comprehensive Accreditation Manual for Hospitals. http://www.jointcommission.org/assets/1/6/2011_NPSGs_HAP.pdf. Accessed May 7, 2011.
  11. 11. California State Senate Bill 739. http://www.dhcs.ca.gov/provgovpart/initiatives/nqi/Documents/SB739.pdf. Accessed January 19, 2012.
  12. 12. Hayashi Y, Paterson DL. Strategies for reduction in duration of antibiotic use in hospitalized patients. Clin Infect Dis 2011;52:1232–1240.
  13. 13. Ohl CA, Dodds Ashley ES. Antimicrobial stewardship programs in community hospitals: the evidence base and case studies. Clin Infect Dis 2011;53(suppl 1):S23–S28.
  14. 14. Septimus EJ, Owens RJ Jr. Need and potential of antimicrobial stewardship in community hospitals. Clin Infect Dis 2011;53(suppl 1):S8–S14.

Additional resources

  1. Carrico R, Archibald LK, Bryant K, et al. Guide to the Elimination of Clostridium difficile in Healthcare Settings. Washington, DC: APIC, 2008.
  2. Dubberke ER, Gerding DN, Classen D, et al. Strategies to prevent Clostridium difficile infections in acute care hospitals. Infect Control Hosp Epidemiol 2008;29(suppl 1):S81–S92.
  3. Siegel JD, Rhinehart E, Jackson M, Chiarello L; Healthcare Infection Control Practices Advisory Committee. Management of Multidrug-Resistant Organisms in Healthcare Settings, 2006. Centers for Disease Control and Prevention Web site. http://www.cdc.gov/hicpac/mdro/mdro_0.html.
  4. World Health Organization. WHO Strategy for Containment of Antimicrobial Resistance. World Health Organization Web site. http://www.who.int/drugresistance/WHO_Global_Strategy_English.pdf.
  5. National Quality Forum Surgical Care Improvement Project. Related and Competing Measures. http://www.qualityforum.org/Projects/s-z/Surgery/Surgery_Related_and_Competing_Measures.aspx.

Acknowledgments

We acknowledge Arjun Srinivasan, MD, FSHEA, for his insightful review and commentary.

Potential conflicts of interest. All authors report no conflicts of interest relevant to this article.

References

  1. 1. Bartlett JG. A call to arms: the imperative for antimicrobial stewardship. Clin Infect Dis 2011;53(suppl 1):S4–S7.
  2. 2. Cuzon G, Naas T, Truong HV, et al. Worldwide diversity of Klebsiella pneumoniae that produce β-lactamase blaKPC-2 gene. Emerg Infect Dis 2010;16:9.
  3. 3. Dellit TH, Owens RC, McGowan JE Jr, et al. Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clin Infect Dis 2007;44:159–177.
  4. 4. Hidron AI, Edwards JR, Patel J, et al. National Healthcare Safety Network Team. NHSN annual update: antimicrobial-resistant pathogens associated with healthcare-associated infections: annual summary of data reported to the National Healthcare Safety Network at the Centers for Disease Control and Prevention, 2006–2007. Infect Control Hosp Epidemiol 2008;29:996–1011.
  5. 5. Kumarasamy KK, Toleman MA, Walsh TR, et al. Emergence of a new antibiotic resistance mechanism in India, Pakistan, and the UK: a molecular, biological, and epidemiological study. Lancet Infect Dis 2010;10:597–602.
  6. 6. Centers for Disease Control and Prevention. Get Smart: Know When Antibiotics Work. Get Smart Web site. http://www.cdc.gov/getsmart/. Accessed November 23, 2011.
  7. 7. Centers for Disease Control and Prevention. Get Smart for Healthcare. Get Smart Web site. http://www.cdc.gov/getsmart/healthcare/?s_cid=dhqp_002. Accessed November 23, 2011.
  8. 8. World Health Organization (WHO). World Health Day: 7 April 2011. Antimicrobial Resistance: No Action Today, No Cure Tomorrow. World Health Organization Web site. http://www.who.int/world-health-day/2011/en/index.html. Accessed November 23, 2011.
  9. 9. Fishman N. Antimicrobial stewardship. Am J Infect Control 2006;34(suppl):S55–S63.
  10. 10. The Joint Commission (TJC). Assets for Acute Care Hospital Accreditation 2011: Comprehensive Accreditation Manual for Hospitals. http://www.jointcommission.org/assets/1/6/2011_NPSGs_HAP.pdf. Accessed May 7, 2011.
  11. 11. California State Senate Bill 739. http://www.dhcs.ca.gov/provgovpart/initiatives/nqi/Documents/SB739.pdf. Accessed January 19, 2012.
  12. 12. Hayashi Y, Paterson DL. Strategies for reduction in duration of antibiotic use in hospitalized patients. Clin Infect Dis 2011;52:1232–1240.
  13. 13. Ohl CA, Dodds Ashley ES. Antimicrobial stewardship programs in community hospitals: the evidence base and case studies. Clin Infect Dis 2011;53(suppl 1):S23–S28.
  14. 14. Septimus EJ, Owens RJ Jr. Need and potential of antimicrobial stewardship in community hospitals. Clin Infect Dis 2011;53(suppl 1):S8–S14.

Additional resources

  1. Carrico R, Archibald LK, Bryant K, et al. Guide to the Elimination of Clostridium difficile in Healthcare Settings. Washington, DC: APIC, 2008.
  2. Dubberke ER, Gerding DN, Classen D, et al. Strategies to prevent Clostridium difficile infections in acute care hospitals. Infect Control Hosp Epidemiol 2008;29(suppl 1):S81–S92.
  3. Siegel JD, Rhinehart E, Jackson M, Chiarello L; Healthcare Infection Control Practices Advisory Committee. Management of Multidrug-Resistant Organisms in Healthcare Settings, 2006. Centers for Disease Control and Prevention Web site. http://www.cdc.gov/hicpac/mdro/mdro_0.html.
  4. World Health Organization. WHO Strategy for Containment of Antimicrobial Resistance. World Health Organization Web site. http://www.who.int/drugresistance/WHO_Global_Strategy_English.pdf.
  5. National Quality Forum Surgical Care Improvement Project. Related and Competing Measures. http://www.qualityforum.org/Projects/s-z/Surgery/Surgery_Related_and_Competing_Measures.aspx.