Last week, I attended the Illinois Summit on Antimicrobial Stewardship at Northwestern Memorial Hospital. While the target audience was physicians, nurses, pharmacists, and administrators, as a clinical laboratory scientist I found the presentations (with a few caveats, which I’ll get to in a moment) quite informative.
The morning sessions covered the relationship between antibiotic use and resistance patterns; interpretations and implementation of the national guideless for stewardship; and using behavioral science to increase compliance with stewardship programs. Participants spent part of the afternoon in small groups to discuss designing and implementing a stewardship program.
A few notes:
-50% of antibiotics for upper respiratory infections aren’t needed; 50% of antibiotics for inpatients aren’t needed, either
-antibiotics are the only drug where use in one person impacts it effectiveness in another
-based on the literature, antibiotic stewardship programs have at least a transient effect on antibiotic effectiveness—eventually, resistance numbers begin to climb again
-hospital antibiograms are the most widely available measure of resistant organisms, but we aren’t using them as effectively as we could. For example, we typically report that, say, “62.5% of E. coli isolates are resistant to ciprofloxacin,” but we don’t say where those isolates come from. Are they urinary tract infections or upper respiratory infections? What’s the rate of resistance for infected wounds?
-a weighted antibiogram might make empirical treatments for effective. For example, “what % of urinary tract infections are resistant to ciprofloxacin?”
-it’s important to note that the IT department, hospital information systems, and laboratory information systems play a huge role in stewardship programs
-stewardship programs depend on the “5 D’s” Diagnosis, drug selection, dose, duration, and de-escalation of use
-diagnostic uncertainty—driven by lack of early organism identification—drives a significant amount of antibiotic use
-when combined with stewardship, rapid bacterial identification methods such as MALDI-ToF platforms decrease parameters such as length of patient say, time to treatment, etc.
-we can use peer pressure to drive improvements. No one wants to perform worse than the doctor next door
-our efforts might be moot, anyway; other countries take a much laxer stance on antibiotic use
While the laboratory in general and clinical microbiology departments specifically were mentioned during the presentations, I must say they were only mentioned in the context of how little perceived impact we have on stewardship. (“Well, we know the laboratory isn’t going to give us any useful information for another three days…”) It wasn’t until I participated in the small group sessions in the afternoon that attendees at my table admitted that the laboratory is an important piece of the stewardship puzzle. We have mountains of data we can assimilate (antibiogram creation, anyone?). We can bring in new technologies to make identifications faster. We can work closely with the infectious disease doctors to help guide treatment. That brings up a good point—if microbiology labs aren’t in-house, then creating an antibiotic stewardship program becomes that much harder because results can be delayed.
If you’d like to see the powerpoints from the presentations, you can do so by clicking the “downloadable content” tab at Northwestern Memorial Hospital’s antibiotic stewardship page.
–Kelly Swails, MT(ASCP), is a laboratory professional, recovering microbiologist, and web editor for Lab Medicine.