Journal of Pharmacy Practice

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Assessment of Antimicrobial Stewardship Activities in a Large Metropolitan Area David M. Jacobs, Kristi Kuper, Edward Septimus, Raouf Arafat and Kevin W. Garey Journal of Pharmacy Practice published online 13 October 2014 DOI: 10.1177/0897190014549842 The online version of this article can be found at: http://jpp.sagepub.com/content/early/2014/10/10/0897190014549842

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Research Article

Assessment of Antimicrobial Stewardship Activities in a Large Metropolitan Area

Journal of Pharmacy Practice 1-6 ª The Author(s) 2014 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0897190014549842 jpp.sagepub.com

David M. Jacobs, PharmD, BCPS1,2, Kristi Kuper, PharmD3, Edward Septimus, MD4, Raouf Arafat, MD, MPH5, and Kevin W. Garey, PharmD, MS6

Abstract Purpose: To describe antimicrobial stewardship programs (ASPs) of acute and long-term acute care (LTAC) hospitals in Houston, Texas. Methods: Two-part survey to clinical pharmacists and pharmacy directors. All acute care and LTAC facilities from the Harris County Medical Society database were invited to participate. Results: In part 1 of the telephone survey, 82 facilities within Houston, Harris county, were contacted by telephone of which 51 responded (response rate: 62%). Of respondents, 55% (n ¼ 28) reported having an active ASP and 8% (n ¼ 4) planned implementation within 12 months. Acute care and LTAC hospitals reported ASPs in 57% and 67% of facilities, respectively. Physician champions were involved in 71% (n ¼ 20) of active ASPs; clinical pharmacists were involved in 75% (n ¼ 21) of programs. In part II, 22 (43%) facilities completed the online survey; postprescription review with feedback was used in facilities with an ASP and medical training program (5 of 5) while formulary restriction was in facilities without stewardship or medical training (6 of 8). Conclusion: This is the first major survey of ASP in a major metropolitan area. The stewardship effort in the city of Houston is encouraging; we expect the number of stewardship programs in all facilities will continue to rise as focus on antimicrobial resistance grows. Keywords anti-infectives, regional survey, antimicrobial stewardship

Introduction Antimicrobial resistance due to the emergence and transmission of resistant pathogens is increasing nationwide.1-3 In 2007, the Infectious Disease Society of America (IDSA) and Society of Healthcare Epidemiology (SHEA) published guidelines for the effective management of antimicrobial stewardship programs (ASPs).4 One goal of the guidelines was to reduce the emergence of resistant pathogens by the careful oversight and use of antimicrobials. High rates of multidrug-resistant pathogens exist across the entire health care community. For example, up to 70% of patients in long-term care facilities may be colonized with a multidrug-resistant organism such as an extended-spectrum b-lactamase producer, methicillin-resistant Staphylococcus aureus, or vancomycin-resistant enterococci.5-7 Almost 1 in 5 hospitals participating in the National Healthcare Safety Network reported carbapenem-resistant phenotype within Klebsiella spp as a cause of infection.8,9 For this reason, the stewardship guidelines stressed the importance of effective management of antimicrobials across the spectrum of care including academic, teaching hospitals, community hospitals, and longterm care facilities including nursing homes. Antimicrobial stewardship initiatives have been organized at the state and national levels including the Center for Disease Control, SHEA, and other professional societies.10,11 The state of

California has mandated that all general acute care hospitals monitor and evaluate the utilization of antimicrobials. However, among urban communities, the capacity and breadth of stewardship activities are relatively unknown. This is important as community-wide outbreaks of multidrug-resistant bacteria have been documented in cities such as New York and San Francisco.12-14 As part of an initiative of the Houston Department of Health and Human Services, a communitywide initiative has been established to coordinate antimicrobial stewardship efforts. In this study, we describe the initial antimicrobial stewardship efforts of acute, long-term acute 1

CPL Associates, LLC, Buffalo, NY, USA Department of Pharmacy Practice, University at Buffalo School of Pharmacy and Pharmaceutical Sciences, Buffalo, NY, USA 3 VHA Performance Services, Houston, TX, USA 4 Clinical Service Group, HCA Nashville, Nashville, TN, USA and Department of Internal Medicine, Texas A&M Health Science Center, Houston, TX, USA 5 Houston Department of Health and Human Services, Houston, TX, USA 6 Department of Clinical Sciences and Administration, University of Houston College of Pharmacy, Houston TX, USA 2

Corresponding Author: David M. Jacobs, University at Buffalo School of Pharmacy and Pharmaceutical Sciences, 313 Kapoor Hall, Buffalo, NY 14221, USA. Email: [email protected]


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care (LTAC), and rehabilitation hospitals in Houston, Texas, and the surrounding Harris county area.

Methods

Table 1. Characteristics of Antimicrobial Stewardship Programs in Harris County (Houston, Texas).

Characteristic

The University of Houston College of Pharmacy in conjunction with the Houston Antimicrobial Stewardship Advisory Committee, Houston Department of Health and Human Services developed and administered a 2 part survey to assess the current state of antimicrobial stewardship. A list of acute care, LTAC, and rehabilitation facilities were assembled from the Harris County Medical Society database. Pharmacy directors or clinical pharmacists for each facility were contacted via phone and asked to participate in the first part of the survey. Questions included whether the facility had an ASP in place (defined as an ASP specifically that had been formally approved and recognized by the medical executive committee), personnel devoted to the program (physician champion and pharmacist), training or subspecialty of the physician and pharmacist, and monitoring methods of antimicrobials. Postgraduate training for pharmacists was defined as completion of a residency or fellowship program following the doctor of pharmacy degree or postgraduate training at the master’s or PhD level. Certificate training included completion of an antimicrobial stewardship training program or attainment of Board of Pharmacy Specialties certification. Following completion of the first survey; participants were asked to fill out a more detailed, electronic survey using an online survey tool, Qualtrics (Provo, Utah). Electronic surveys were distributed via e-mail to pharmacists who agreed to participate. Reminders were sent every 2 weeks up to 2 times. Questions asked were focused on core and supplemental stewardship strategies performed within the facility, methods used to restrict antimicrobials at facilities without an ASP, and what educational opportunities would be useful to improve knowledge and skills on antimicrobial resistance. Both surveys were voluntary, and no incentives were given for participation. No individual participant identifiers were collected. Eighty-two facilities were identified through the Harris County Medical Society and used as the denominator in the analysis. All information was deidentified. This study was deemed exempt from review by the Committee for the Protection of Research Subjects at the University of Houston.

Statistical Analysis Facilities were deidentified, and results are presented in aggregate. Continuous variables were reported using means and standard deviations; categorical variables were reported using frequencies and proportions. Data analyses were performed with Microsoft Excel (Microsoft Inc, Redmond, Washington).

Results Phase I Telephone Survey Antimicrobial stewardship programs in Harris County (Houston, Texas). Eighty-two facilities within Houston, Harris County,

No. of respondents Type of facility Acute care hospital Long-term acute care (LTAC) Rehabilitation Type of acute care hospital Community Academic/teaching hospital Average daily census 100 101-250 251-500 500 Monitoring use of antibiotics Defined daily dose Days of therapy Annual purchasing costs, US$ Current antibiogram Yes No

ASP within Current ASP, 12 months, No ASP, No. (%) No. (%) No. (%) 28

4

19

20 (71) 8 (29) 0

2 (50) 2 (50) 0

13 (68) 2 (11) 4 (21)

14 (70) 6 (30)

1 (50) 1 (50)

13 (100) 0

12 (43) 10 (36) 3 (11) 3 (11)

2 (50) 2 (50) 0 0

16 (84) 3 (16) 0 0

13 (46) 14 (50) 17 (61)

1 (25) 1 (25) 0

5 (26) 5 (26) 5 (26)

28 (100) 0

4 (100) 0

13 (68) 6 (32)

Abbreviation: ASP, antimicrobial stewardship program.

were contacted with responses from 51 (62%) facilities (Table 1). Of the 51 facilities, 28 (55%) currently had an ASP in place. An additional 4 (8%) facilities had plans to implement an ASP within 12 months. All current ASPs were approved by the medical executive committee of their institutions. Acute care and LTAC hospitals reported having a stewardship program in 57% and 67% of facilities, respectively. Sixty-one percent of facilities with an ASP monitored the use of antibiotics through annual purchasing costs. In addition, days of therapy and defined daily dose were used in 50% and 46% of facilities with stewardship programs, respectively. All facilities with a stewardship program prepared an antibiogram on at least an annual basis. The locations of the responding facilities are shown in Figure 1. Of the 32 facilities, 22 (69%) with a current or pending stewardship program were located within a 15-mile radius from the Texas Medical Center (TMC), the major health care center in the region. Of the 19 facilities, 13 (68%) that indicated they did not have a stewardship program were found outside the 15 mile radius from downtown Houston and the TMC. Antimicrobial stewardship program personnel in acute care and LTAC hospitals. Differences in physician and pharmacist involvement within the ASPs between acute care and LTAC facilities are summarized in Table 2. A physician champion was a member of the ASP in 12 (60%) of the 20 acute care hospitals compared to 8 (100%) of the 8 involvement in LTAC facilities. Of the acute care hospitals that had a physician champion, 5 (41%) of the 12 were compensated for stewardship activities compared to 3 (38%) of the 8 in LTAC hospitals.


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Figure 1. Locations of ASPs in the Greater Houston Metropolitan Area. ASP indicates antimicrobial stewardship program.

Table 2. Personnel Specifics of the Established Antimicrobial Stewardship Programs.

Personnel specifics within ASP Physician-specific information Physician champion Infectious disease specialty Physician compensation Pharmacist-specific information Clinical pharmacist involved in ASP No. of pharmacists with postgraduate traininga No. of pharmacists with certificate trainingb

Acute care hospital, N ¼ 20, No. (%),

Long-term acute care (LTAC), N ¼ 8, No. (%)

12 (60) 12 (100) 5 (41)

8 (100) 6 (75) 3 (38)

16 (80) 11 (69)

5 (63) 0

2 (12)

2 (40)

Abbreviation: ASP, antimicrobial stewardship program. a Includes postgraduate year 1 (PGY-1) and postgraduate year 2 (PGY-2) residency programs or fellowship training. b Includes antimicrobial stewardship certificate training programs or Board of Pharmacy Specialties certificate.

A clinical pharmacist was involved in the ASP at 16 (80%) of the 20 acute care hospitals compared to 5 (63%) of the 8 LTAC facilities. Among the clinical pharmacists within an acute care hospital involved in stewardship, 11 (69%) had postgraduate training and 2 (12%) had certificate training. In the LTAC setting, none of the clinical pharmacists completed postgraduate training, but 2 (40%) had certificate training. Barriers to implementation of an ASP. Respondents without a functioning ASP were asked to describe the barriers to implementation. Most common responses included lack of funding or personnel (37%) or lack of prescriber interest (37%). Additional responses included lack of information technology support (5%) or administration not aware of value of ASP (11%).

Phase II Follow-Up Detailed Survey Fifty-one respondents from survey 1 were asked to complete an online survey; 22 (43%) completed responses were analyzed (Table 3). In all, 44% of acute care and 25% of LTAC


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Table 3. Characteristics of the Antimicrobial Stewardship Programs From the Online Survey. Characteristic No. of respondents Type of facility Acute care hospital Long-term acute care (LTAC) Type of acute care hospital Academic/teaching Community, medical training Community, no medical training Average daily census of all facilities 100 101-250 251-500 500

Current ASP, No. (%)

No ASP, No. (%)

9

13

8 (44) 1 (25)

10 (56) 3 (75)

3 (75) 2 (66) 3 (27)

1 (25) 1 (33) 8 (73)

2 2 2 3

5 4 3 1

(29) (33) (40) (75)

(71) (67) (60) (25)

Abbreviation: ASP, antimicrobial stewardship program.

respondents currently have an ASP. Sixty-three percent of programs with an ASP also had a medical training program. Of the facilities without an ASP, 80% were located in community hospitals without a medical training program. Antimicrobial Stewardship strategies. Postprescriptive review with feedback was the core strategy utilized in 100% (5 of 5) acute care facilities with an antimicrobial stewardship and medical training program (Table 4). Six of eight (75%) facilities without a stewardship or medical training program utilized formulary restriction to control the use of antibiotics. Two of three (66%) LTAC hospitals without a stewardship program utilized a combination of formulary restriction and postprescriptive review to control the use of antibiotics. A variety of supplemental strategies were utilized in acute hospitals regardless of an established antimicrobial stewardship or medical training program. All medical training hospitals with an ASP (5 of 5) utilized guidelines, education, and streamlining as part of their stewardship activities. In hospitals without medical training or stewardship, the most common supplemental strategies included guidelines (6 of 8), oral to parenteral conversion (5 of 8), and dose optimization (5 of 8). The LTAC facilities without a formal stewardship program utilized oral to parenteral conversion (3 of 3), education (2 of 3), and streamlining (2 of 3) as their supplemental strategies.

Discussion Outbreaks of resistant organisms (ie, carbapenem-resistant Enterobacteriaceae and multidrug-resistant Acinetobacter baumannii) have been reported in New York San Francisco and Chicago.12,14,15 These pathogens were disseminated throughout the community and not limited to major medical centers.16 Due to the emergence of resistance and a decline in novel antibiotics over the past decade, a number of organizations have recognized the importance of implementing stewardship

programs.2,3 Surveys of stewardship practices within acute care hospitals have been published at a state and national level.10,11,17-19 Our survey describes the extent to which ASPs have been implemented in acute care and LTAC hospitals within a large metropolitan area. Houston, Texas houses the TMC. The TMC is the largest medical center in the world and thus dominates the health care network of the city and surrounding counties. The major academic, tertiary care medical centers of the TMC are located near downtown Houston with each medical system owning smaller community hospitals around the city. In addition, multiple other health care facilities exist in the city including LTAC hospitals and rehabilitation facilities. In our survey, 55% of acute care hospitals in the greater metropolitan city of Houston had an existing ASP. Institutions located close or within the TMC were more likely to have an active or pending ASP. Regardless of the presence of a medical executiveapproved ASP, most hospitals in our survey employed core or supplemental ASP activities. To our knowledge, this is the first survey that analyzes the stewardship efforts at a city level of a large urban area. A state-level stewardship survey by Abbo et al showed that 55% of responding acute care facilities in Florida reported an existing ASP.11 A similar survey in Massachusetts showed that 70% of responding institutions had an established ASP.10 A recent article by Trivedi and Rosenberg showed that 50% of responding institutions in California were involved in antimicrobial stewardship, with a legislative mandate playing a role in initiating many hospital ASPs.20 In our survey, 63% of respondents had an existing or pending ASP agreeing well with the results of the state-wide surveys. Stewardship in LTAC hospitals in Houston was greater than expected. Sixty-seven percent of LTAC hospitals reported having a current ASP. Of the 8 LTAC hospitals with stewardship, 5 were part of the same health care system, which mandated stewardship programs approved by the medical executive staff. Currently, there are limited data that examine stewardship in an LTAC setting.21-23 The literature describes the development of ASPs in single-center LTAC hospitals. We were able to show there is a strong presence of antimicrobial stewardship in these facilities within the city of Houston. Our findings are promising given the rise in reports of outbreaks of highly resistant organisms and misuse of antibiotics in this setting.5,24 The 2007 IDSA guidelines on antimicrobial stewardship discussed the importance of having a clinical pharmacist with infectious disease (ID) training and a physician champion as core members of the multidisciplinary antimicrobial stewardship team.4 Our findings show that the stewardship team within LTAC hospitals all had physician champions (8 of 8); however, only 5 had a pharmacist a part of the team. Of the 5 pharmacists who were involved in an ASP, none had additional postgraduate training. A survey on antimicrobial use and management reported the percentage of community hospitals with an ID physician or pharmacist was 59% and 7%, respectively.25 Resource limitation is a major challenge with all facilities and has been identified as a barrier that may limit a community hospital’s ability to fully comply with IDSA guidelines.26 In 2012,


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Table 4. General Acute Care Hospital Respondent Antimicrobial Strategies, Sorted by Presence of Medical Training, and Antimicrobial Stewardship Program (ASP), Houston, Texas, 2012. No. (%) of respondents Medical training program Strategy Primary Formulary restriction Preauthorization Postprescription review with feedback Supplemental Education Intravenous to oral conversion protocols Dose optimization Guidelines and clinical pathways Streamlining/de-escalation

No medical training program

Current ASP (n ¼ 5)

No ASP (n ¼ 2)

Current ASP (n ¼ 3)

No ASP (n ¼ 8)

5 (100) 1 (20) 3 (60)

2 (100) 1 (50) 1 (50)

1 (33) 1 (33) 1 (33)

6 (75) 1 (13) 2 (25)

5 4 4 5 5

1 (50) 1 (50) 0 1 (50) 0

3 (100) 3 (100) 3 (100) 2 (66) 2 (66)

3 5 5 6 4

(100) (80) (80) (100) (100)

Pate et al reported on a stewardship program within an LTAC hospital comprised of an ID physician and a pharmacist without specialized ID training.21 The stewardship team was able to reduce the monthly antimicrobial and cost per patient day by 21% and 28%, respectively. Pharmacists play a pivotal role within a stewardship program, but there are too few ID trained pharmacists.25 It is imperative that clinical pharmacists are trained to have competencies for antimicrobial stewardship in order to assist in ASPs in all types of institutions. Regardless of the presence of a medical training or ASP in an acute care hospital, all respondents to the online survey utilized both core and supplemental strategies as described by the IDSA/SHEA guidelines.4 This finding aligns with previous surveys that showed stewardship strategies, both core and supplemental, being performed in facilities without a formal program.11,26 The LTAC facilities showed a similar response in the online survey as compared to acute care hospitals. The LTACs without a formal ASP utilized both postprescriptive review and formulary restriction as its core strategies. In the published works on LTAC stewardship programs, weekly to biweekly prospective chart review with feedback was the chosen core strategy.21,22 Our study has limitations. Both of the surveys were selfreported, and the answers could not be validated. We were not able to determine the effectiveness of the existing stewardship programs. The response rate in survey 2 was disappointing. However, we believe it provides additional information on LTAC facilities that is currently unavailable. A more detailed analysis of core and supplemental stewardship strategies in LTAC facilities is warranted.

Conclusion This survey demonstrates the current stewardship practices in acute care and LTAC facilities in a large metropolitan city. We found the stewardship efforts within the greater city of Houston to be encouraging with 57% of acute care and 67% of LTAC respondents have an ASP. As city, state, and national

(38) (63) (63) (75) (50)

organizations begin to focus on the antimicrobial resistance problem, we expect the number of stewardship programs in all facilities will continue to rise. Further research is needed to examine national measures as it pertains to antimicrobial stewardship and effective implementation strategies of antimicrobial stewardship across the continuum of care. Authors’ Note During the time this study was conducted, Dr Jacobs was an Infectious Diseases Resident, University of Houston College of Pharmacy/Cardinal Health, Houston, TX, USA. All authors contributed to the design, execution, analysis, and writing of this study.

Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.

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