For the second in our In Depth series, I have chosen Antimicrobial Stewardship in the Emergency Department.
Our exploration of the topic was prompted by notice of progressive facility partners initiating programs aimed at meeting this goal, and enlisting our organization, and our affiliated providers, in the effort to enact the steps necessary to accomplish that goal.
The programs were responsive to the Centers for Medicare and Medicaid Services (CMS) Final Rule on Antibiotic Stewardship, explained here by the ASM:
On September 30, 2019, CMS released a final rule that addresses antibiotic stewardship programs. This rule “Regulatory Provisions to Promote Program Efficiency, Transparency, and Burden Reduction; Fire Safety Requirements for Certain Dialysis Facilities; Hospital and Critical Access Hospital (CAH) Changes To Promote Innovation, Flexibility, and Improvement in Patient Care,” was first proposed in 2016. The rule requires all acute-care hospitals that participate in Medicare or Medicaid to develop and implement an antibiotic stewardship program as part of their infection control efforts. Two sections, § 482.42(b) and § 485.640(b), regarding hospital and critical access hospital (CAH) antibiotic stewardship programs, must be implemented by March 30, 2020.
482.42 requires the hospital to:
- Provide a sanitary environment to avoid sources and transmission of infections and communicable diseases
- Develop an active program for the prevention, control, and investigation of infections and communicable diseases, and
- Assign a designated infection control officer
§ 485.640 requires the following goals for an antibiotic stewardship program be met:
- Coordination among all components of the CAH responsible for antibiotic use and resistance, including, but not limited to, the infection prevention and control program, the QAPI program, the medical staff, and nursing and pharmacy services;
- Document the evidence-based use of antibiotics in all departments and services of the CAH; and
- Demonstration of improvements, including sustained improvements, in proper antibiotic use, such as through reductions in, CDI and antibiotic resistance in all departments and services of the hospital.
According to APIC,
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
Clinicians practicing in the Emergency Department have an important role in the effort, and face unique challenges.
From an interview in ID Stewardship:
There are a number of challenges related to antimicrobial stewardship in the emergency department (ED), but I think most originate from the fact that traditional antimicrobial stewardship activities that are conducted in areas outside of the ED are not easily replicable within the ED.
For one, the rate of patient turnover in the ED is relatively high compared to any other area within an institution. Second, patient disposition varies substantially from the “treat and street” to those requiring admission to the critical care units. Third, ED pharmacists work with a mixed provider population. This can present challenges for developing systematic antimicrobial stewardship processes.
There is a certain element of creativity that must be incorporated into the underlying science of determining what types of stewardship activities can be conducted related to the use of antimicrobials in the ED. The prescribing of broad-spectrum antimicrobials is certainly not the answer for all patients and how to mitigate unnecessary prescribing will likely vary from institution to institution.
It is important that healthcare workers (including pharmacists, nurses and prescribers) work together at the point of care to optimize the use of antimicrobials as it relates to the triad of suspected bugs, drugs, and patient factors.
The American College of Emergency Physicians (ACEP) published a concise overview and recommendations for 5 Tips to Improve Antibiotic Stewardship in the Emergency Department, which includes this 5D system
When we unnecessarily prescribe antibiotics for viruses, misdiagnose noninfectious conditions (eg, pseudocellulitis), or provide suboptimal antibiotic regimens, we exert selective pressure on our local community’s biome. Selective pressure encourages resistant bacteria to thrive by killing off weaker bacteria.
It is not too late. We are living in a crucial time. The prevalence of superbugs remains low in most communities. By practicing what we call the “5 D’s of antibiotic stewardship”—right diagnosis, right drug, right dose, right duration, right de-escalation—we can reduce the prevalence of MDROs in our hospitals and communities.5 Future generations will thank us—or better yet, they won’t even realize they have to.
Meet the 5 D’s
Here are the 5 D’s applied to emergency medicine practice.
- Right Diagnosis: Take a diagnostic stand and call a virus a virus. Acute otitis media, bronchitis, sinusitis—all of these entities are far more often viral than bacterial. When the patient is not seriously ill, is not immunocompromised, and clearly had a recent viral prodrome, you can usually avoid antibiotics.
- Right Drug: For patients with uncomplicated bacterial infections that require antibiotics, consult your institution’s ED antibiogram to identify the most common causative organism and narrowest spectrum agent that is typically effective (eg, nitrofurantoin for Escherichia coli).
- Right Dose: Practice weight-based dosing of antibiotics for pediatric patients, and for noncritically ill adults, err on the low side of the suggested dose range.
- Right Duration: It is a poorly-kept secret in medicine that the recommended length of most antibiotic regimens was chosen arbitrarily in initial studies and has been subject to inertia ever since. When offered a range of duration of therapy, choose the shortest duration. If you are prescribing any antibiotic for more than seven days, favor a shorter course.6–9
- Right De-escalation: Antibiotic de-escalation is a new trend in emergency medicine. Emergency physicians make decisions that generate therapeutic momentum for inpatient antibiotic prescribing. The act of simply writing in the chart, “These broad-spectrum agents should be narrowed to a single-effective agent once culture results have returned,” can save your patients days of unnecessary antibiotics.
ACUTE CARE, INC. believes in, supports, and is serving as a willing partner in implementing effective strategies to advance the cause of antibiotic stewardship.