Raising the Bar on Antimicrobial Stewardship: The Evolution of a Comprehensive Program Model Using a Multifaceted, Rapid Sequence Approach
Benjamin D. Brielmaier, Pharm.D., BCPS (AQ-ID), Natasha N. Pettit, Pharm.D., BCPS, Emily Landon, M.D., Jennifer Pisano, M.D., Palak Bhagat, Pharm.D., BCPS, Allison Bartlett, M.D., Dave Hicks, R.Ph., M.B.A., Heath R. Jennings, Pharm.D., BCPS (AQ-Cardiology)
The University of Chicago Medicine, Chicago, Illinois
Antimicrobial stewardship programs (ASPs) are commonly implemented to facilitate safe and optimal utilization of antimicrobials through coordinated interventions. An antimicrobial restriction program utilizing a clinical pharmacist with infectious disease (ID) training was implemented at our institution in the mid-2000s. In August 2010, a more robust, comprehensive program was established to oversee both adult and pediatric patient populations. This was accomplished in conjunction with an ongoing institutional comprehensive pharmacy practice model expansion.
The ASP at our institution rapidly expanded over the course of approximately two years from a single ID pharmacist to its current structure of seven individuals. Leadership consists of an ID pharmacist and ID physician who serve as the Pharmacy and Medical Directors. Our composition (three pharmacists, three physicians, one pharmacist trainee) has allowed us to further align ourselves with key patient populations and form pharmacist-physician “teams” responsible for coordinating efforts in three target areas: general ID, immunocompromised hosts, and pediatrics. The framework for the evolution of the ASP was built upon four pillars we considered to be fundamental to its success: safety, interdisciplinary collaboration, education, and resource utilization. Initiatives were undertaken simultaneously across multiple fronts to achieve balanced improvements in each of these areas.
Key safety initiatives included development of institutional clinical pathways and guidelines, computer-based surveillance alerts, standardized dosing recommendations, and pharmacist-managed dosing services. The ASP partnered with several key groups within the institution to improve patient care practices, including infection control (IC), hematology-oncology, clinical microbiology, quality, and surgery. Collaboration with IC on a shared goal of institutional carbapenem-resistant Enterobacteriaceae (CRE) reduction resulted in a 45% decrease in CRE rates from 2010 to 2012. An internal ASP webpage was developed as a targeted educational initiative and receives an average of 980 visits per month. Utilization of all high impact antimicrobials decreased in response to ASP initiatives. The most significant decreases were observed with linezolid (47%), carbapenems (37%), and voriconazole (32%). Total antimicrobial expenditure per patient day decreased from $38.32 in fiscal year (FY) 2010 (prior to ASP activities) to $34.36 in FY2012, with an estimated cost reduction of $421,580 per year. “Workhorse” antipseudomonal agent expenditure per patient day decreased by 54% between FY2010 and FY2012 following formulary changes in 2011, with an estimated yearly expenditure reduction of $250,000. A total of 4,855 antimicrobials were reviewed from August 2010 to June 2012. This resulted in 1,353 interventions with a 93% prescriber acceptance rate. Interventions were most frequently related to optimization of therapy (52%) followed by safety (24%).
The comprehensive nature and structure of our program (utilizing pharmacist-physician “teams”) has been vital to its advancements. The multifaceted, rapid sequence approach adopted by our program, consisting of strategic implementation of interventions, policies, and practices simultaneously across multiple fronts, was feasible and resulted in decreased rates of resistance, improved patient safety, and decreased antimicrobial utilization and expenditures over the course of approximately two years.
View a pdf of the poster from the Midyear Meeting (207 KB)