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Improving Patient Care Through a Collaborative and Innovative Antimicrobial Stewardship Program

Catherine Baker, Pharm.D., Paul Sehdev, M.D., Woody English II, M.D., Nancy Church, R.N., C.I.C, Steve Stoner, Pharm.D.

Providence St. Vincent Medical Center, Portland, Oregon

Inappropriate antimicrobial use contributes to increased patient morbidity and mortality, adverse drug reactions, emergence of multidrug-resistant organisms and healthcare-associated infections, and increased healthcare costs.  This report describes the evolution of an antimicrobial stewardship program in our health-care system.  Traditional elements for antimicrobial stewardship are summarized and innovative roles in recently introduced regulatory initiatives in the inpatient environment driving collaborative efforts to improve patient care through optimal antimicrobial use are highlighted.
Our Antimicrobial Monitoring Service (AMS) was established in 1997 to promote cost-effective antimicrobial use to improve patient care.  AMS is a multidisciplinary service including pharmacists, ID physicians, nurses, physician specialists, and personnel from microbiology and infection control.  Core elements of AMS include antimicrobial patient care rounds and antimicrobial guideline development.  Traditional antimicrobial stewardship interventions were incorporated into the daily activities of the AMS. The introduction of pay-for-performance incentives pertaining to healthcare-associated infections offered further opportunities for collaborative efforts to improve antimicrobial use.  Members of the AMS have become actively involved in efforts targeting initiatives related to antimicrobial use and prevention of healthcare-associated infections.   Important changes  include incorporation of clinical pharmacists into daily AMS activities and implementation of computerized systems for identification of patients for potential intervention and standardized documentation of interventions.
Initial data collection (1998 – 2002) identified 783 interventions over a five year period, demonstrating an average acceptance rate of 77%. Despite a variety of drivers for increased antimicrobial use and expenditures, antimicrobial expenditures declined as a proportion of total pharmaceutical expenditures (13.8% to 12.9%) over the five years.  In 2005, AMS involvement expanded to include participation in multidisciplinary efforts related to prevention of healthcare-associated infections, particularly in protocol development for adult surgical antibiotic prophylaxis. Improvements in perioperative prophylaxis resulted in an estimated additional 2200 cases receiving timely antibiotic prophylaxis, 1800 cases having appropriate antimicrobial selection, and 3600 cases having timely discontinuation of perioperative antibiotic prophylaxis annually.  Following a change in pharmacy structure and implementation of computerized systems to assist with interventions, the most recent data suggests a combined direct cost savings and cost avoidance of greater than $300,000 annually associated with antimicrobial interventions.
Antimicrobial stewardship presents opportunities for pharmacists to be involved in multidisciplinary efforts to impact patient care through improving antimicrobial use.  Our AMS utilizes a multifaceted approach to antimicrobial stewardship, incorporating both traditional and innovative roles for improving patient care. 

References:
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; 44:159-77.
MacDougall C, Polk RE.  Antimicrobial stewardship programs in health care systems. Clin Microbiol Rev. 2005; 18:638-56.
Owens RC Jr. Antimicrobial stewardship:  concepts and strategies in the 21st century. Diagn Microbiol Infect Dis. 2008; 61:110-28.
Owens RC Jr, Fraser GL, Stogsdill P. Antimicrobial stewardship programs as a means to optimize antimicrobial use. Pharmacotherapy. 2004; 24:896-908.
Yates RR. New intervention strategies for reducing antibiotic resistance. Chest. 1999; 115 (suppl 3):24S-27S.

View a pdf of the poster from the Midyear Meeting (430 KB).