Antimicrobial stewardship in the clinic

With more people dying of antibiotic-resistant infections, the U.S. is in the middle of a dangerous and unpredictable situation.

Last November, the CDC released its 2019 report on antibiotic resistance, which found that 48,700 people in the U.S. die each year due to antibiotic resistance or Clostridioides difficile infection. That figure is up from about 37,000 in 2013.

As a parent, David W. Baker, MD, MPH, FACP, has concerns about what this means for the future. “This problem terrifies me,” he said. “My grandkids could be growing up in an era where they've got infections that are not treatable because we don't have effective antibiotics.”

But Dr. Baker also has a role in taking action as executive vice president of health care quality evaluation for The Joint Commission. Three years after the organization required accredited hospitals to have antimicrobial stewardship programs, the time has come for clinics to follow suit. As of Jan. 1, 2020, all accredited ambulatory practices, including those providing medical or dental services and urgent care, must meet new antimicrobial stewardship requirements.

“We're not witnessing the release of many new drugs lately, and resistance is increasing every year,” Dr. Baker said. “So we all need to get on board with antibiotic stewardship.”

The new standard

The Joint Commission's new standard is based on the CDC's core elements of outpatient antibiotic stewardship. It requires practices to complete five elements of performance that address antimicrobial stewardship in the ambulatory setting: 1) Identify an individual to lead stewardship efforts, 2) Set at least one annual stewardship goal, 3) Use evidence-based practice guidelines to meet goals, 4) Educate all clinical staff about appropriate antimicrobial prescribing practices, and 5) Collect, analyze, and report data back to organizational leadership and prescribers.

Essentially, an organization should choose one problem and focus on that, Dr. Baker said. “We've taken a very targeted approach,” he said. “We've told organizations, ‘Sure, there are many targets that you could pursue, but just choose one.’”

While the standard doesn't tell practices exactly how to meet the new requirements, experts shared some insight as to what might work best.

For the first requirement of choosing a stewardship champion, the best person for the job is typically an active clinician, said Jeffrey A. Linder, MD, MPH, FACP, who was part of the technical expert panel that advised The Joint Commission on the standard.

“It's the busiest people, but it's also the people who understand the pressures of having a patient there who's saying, ‘I'm here for my Z-Pak,’” he said. “I think that gives the stewardship champion a lot more credibility.” Plus, the leader must be someone who is comfortable with having conversations with physicians who are potentially not prescribing antibiotics appropriately, Dr. Linder said.

Involving all staff members in stewardship efforts, from nurses to medical assistants, as noted by the fourth element in the Joint Commission standard, is vital, Dr. Baker said.

“You need to get everybody in your practice, and ideally everybody in the community, together,” he said. “All of us internists and family physicians need to be on board with this, because if a patient is unhappy and they leave your office and they go down the street to an urgent care center and that doctor or nurse gives an antibiotic, it decreases the physician's credibility.”

When thinking about which data to measure, Dr. Linder said go for the low-hanging fruit. “The lowest-hanging fruit for most primary care and urgent care practices is in obviously inappropriate antibiotic prescribing,” he said.

There seems to be plenty of fruit within reach. In a study published in January 2019 by The BMJ, Dr. Linder and others looked at ambulatory antibiotic prescribing in the U.S. in 2016. Of about 15.5 million antibiotic prescriptions filled, about 23% were inappropriate, and about 29% weren't associated with a recent diagnosis code. In the inappropriate category, the top diagnoses were the usual offenders, such as acute bronchitis, colds, and other respiratory symptoms.

Therefore, Dr. Linder recommended setting goals to avoid antibiotic prescribing for these types of conditions. “If you were going to measure one thing in a practice, that's what I would advise practices to start with,” he said.

Some practices will face challenges in meeting the standard, particularly with regard to managing data, experts said. Some may have a difficult time obtaining data in the first place, and some may not be familiar with reporting data both at the practice and prescriber level, Dr. Linder said. “That's not trivial. … It's actually really hard, particularly if you're a practice that's in a bigger system. You have to know who to talk to, and if it's not an organizational priority, it can be very hard to develop and generate new reports,” he said, adding that the process can sometimes take a year.

While the standard does not require a multidisciplinary team, one way ambulatory practices can get the data they need is through building partnerships, said infectious diseases physician Susan C. Bleasdale, MD, FACP, a member of the standards review panel for the standard. For example, pharmacists and informatics specialists can help with getting prescribing data from the EHR, and a local laboratory or hospital can help with getting regional antibiogram data, she said.

There is substantial variability between practices. Dr. Linder said he has seen sophisticated data extraction and analytic capabilities in both large organizations and small practices, where a doctor who was an early computer adopter might take the lead.

Dr. Baker agreed that data monitoring will be the most difficult part of complying with the standard, although The Joint Commission is not very prescriptive about it. “If you just have the resources to review 100 charts, do that,” he said. “And hopefully over time, there will be better tools within electronic health record systems to simplify [assessment of] prescribing patterns.”

The standard applies only to accredited practices, and there are more than 2,200 freestanding ambulatory care organizations accredited by The Joint Commission. However, “It's the minority of ambulatory practices that are Joint Commission-accredited,” said Dr. Linder, who is chief of the division of general internal medicine and geriatrics and a professor of medicine at the Northwestern University Feinberg School of Medicine in Chicago.

Although it doesn't apply to every outpatient practice, the requirement is still a step in the right direction, said Dr. Bleasdale, who is an associate professor of clinical medicine and medical director of infection prevention and antimicrobial stewardship at the University of Illinois at Chicago. “I think that this is a first step forward toward decreasing antimicrobial resistance, which will have an impact on outcomes for our patients.”

Some outpatient practices are already moving beyond what's required. For example, stewardship efforts in primary care and dentistry started around 2016 at the University of Illinois at Chicago, Dr. Bleasdale said. “It's not just about following recommendations; we follow what we think is best practice. So there's a lot of what we do that we've done before it's been required.”

Not all practices are as prepared. That's why the Agency for Healthcare Research and Quality Safety Program for Improving Antibiotic Use aims to advise a cohort of practices on how to improve their prescribing practices and extract their data, said Dr. Linder, primary care clinician-investigator for the program. Participating practices will meet The Joint Commission standard, as well as some of the CMS Merit-based Incentive Payment System (MIPS) measures, he noted.

Through monthly training sessions, the program will help outpatient practices “get on the same page” about antibiotics, both clinically and culturally, Dr. Linder said. One cultural example is that by the time a patient has gone to the trouble to come into the office, it's difficult to deliver the message that antibiotics aren't needed. The program advises practices on how to prevent that encounter in the first place by triaging patients who call with respiratory symptoms, Dr. Linder noted. “It's the visit itself that puts the person at risk for getting an unnecessary antibiotic.”

As of November 2019, the program was in the process of enrolling more than 250 primary care and urgent care practices throughout the U.S., he said. Starting this month, the program (which has concluded enrollment) aims to receive monthly data from participating practices about antibiotic use overall and for particular diagnoses.

Signs of progress

For as big a problem as antibiotic overuse is, there have been signs of progress. An analysis by Blue Cross Blue Shield showed that outpatient antibiotic prescription rates decreased by 9% from 2010 to 2016 in the United States. A study presented at the American Public Health Association meeting in Philadelphia in November 2019 also found that overall antibiotic prescriptions dispensed at U.S. pharmacies and long-term care facilities decreased by about 5% from 2014 to 2018.

But even though every internist knows not to treat viruses with antibiotics, inappropriate prescriptions are still being filled, Dr. Linder said. “This is not a knowledge problem,” he said. “It's a social and health care system problem where, for a variety of reasons, doctors continue to prescribe inappropriate antibiotics.”

Some of the top reasons he's heard from doctors are that they believe patients want antibiotics (and they want patients to be satisfied with their care) and that they are concerned about potential complications. These issues coalesce into one central theme: “It's really complicated to not prescribe antibiotics, and it's just much simpler to prescribe patients antibiotics,” Dr. Linder said.

In some respects, this theme remains true now more than ever. “Some health care professionals are actually paid partially on patient satisfaction, and then urgent care centers in particular, their whole business model is on getting people what they want conveniently and quickly,” he said. “So in some respects, it's almost as bad as it's ever been.”

Taking antibiotics will not change the reality that colds can take between five and 14 days to run their course, Dr. Linder said. Of course, that's not satisfying for patients to hear when they are sick, which is a challenge for internists.

One potential solution is to talk to patients using a positive framework, Dr. Baker said. “I start off with a positive message: It is good news to not need an antibiotic. … We're protecting patients, we're protecting their children and future generations, so we need to all get that message out,” he said.

For the more reluctant patients, it might help to point out potential harms as well, Dr. Linder said. “I actually have a colleague whose favorite phrase that I've picked up if somebody starts to get a little argumentative is, ‘You know, right now you have a cold. And if I give you an antibiotic, then you're going to have a cold and diarrhea, so just stick with the cold.’”

It's important not to assume that patients think antibiotics are magic drugs, and most are receptive to appropriate advice, Dr. Linder said. He also recommends against lecturing a sick patient about antibiotic resistance because in studies, it doesn't seem to help, he said. “It's like, ‘What do I care about what happens to society? I want to feel better.’”

Overall, clear and thorough communication with patients about appropriate antibiotic prescribing is key, Dr. Linder said. “The vast majority of patients are perfectly delighted as long as they understand, feel like you paid attention to them, explained their illness, explained why antibiotics won't work, and gave them a contingency plan,” he said.

The future of antibiotic stewardship is unclear, but experts said they are hopeful. For instance, with the inpatient setting years ahead of the outpatient setting on this issue, there has been measurable progress in hospitals. For example, in 2014, only 41% of hospitals had the CDC's core elements to guide antibiotic stewardship efforts in place, compared to 85% in 2018, according to the CDC. Then, in September 2019, CMS made it a condition of participation for hospitals to have antibiotic stewardship programs.

“I think this is going to move that needle all the way up to 95% to 100% for centers, so this [Joint Commission] requirement is hopefully going to have an impact in putting resources into the ambulatory setting,” Dr. Bleasdale said. For example, the Healthcare Effectiveness Data and Information Set (HEDIS) measures include avoidance of antibiotic treatment in adults with acute bronchitis. “I think that that just needs to be weighted a little more heavily as this requirement moves forward,” she said.

In addition, new tools, such as infectious diseases support through telehealth and data sharing and integration through the EHR, could be a helpful resource for physicians, Dr. Bleasdale said. Dr. Baker agreed, adding that these tools offer opportunities to make it easier to prescribe appropriately.

“There's so much pressure that doctors face, we need to make it easy to do the right thing,” he said. “There's no area that that is more apparent, I think, than antimicrobial stewardship, but I'm very optimistic.”