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Program seeks to optimize appropriate use of antibiotics

Nov. 10, 2016, 8:26 AM

Whitney Jones, Pharm.D., consults with a Vanderbilt University Hospital clinical team about a patient’s antimicrobial therapy. (photo by Joe Howell)
Whitney Jones, Pharm.D., consults with a Vanderbilt University Hospital clinical team about a patient’s antimicrobial therapy. (photo by Joe Howell)

Relying on a core team of physicians and pharmacists, the Vanderbilt Antimicrobial Stewardship Program (VASP) is seeking to ensure optimum use of antibiotics and other antimicrobial drugs at Vanderbilt University Medical Center (VUMC).

The program was established in 2009 by infectious diseases specialists Patty Wright, M.D., and Titus Daniels, M.D., MPH, MMHC, with a focus on inpatient areas of Vanderbilt University Hospital (VUH). In March 2012 the program was expanded to inpatient areas of the Monroe Carell Jr. Children’s Hospital at Vanderbilt.

VASP remains limited to inpatient settings for the time being.

“The purpose of VASP is to increase appropriate use of antimicrobials, to achieve better and safer care,” said Ritu Banerjee, M.D., Ph.D., associate professor of Pediatrics and director of VASP for Children’s Hospital.

“If you can prevent overuse and misuse of antibiotics, you’ll hopefully also reduce the emergence and spread of resistant bacteria and achieve cost savings,” she said.

Optimizing antimicrobial use means “optimizing the dose, duration of therapy, selection of antimicrobial agent and route of administration,” said George Nelson, M.D., assistant professor of Medicine and director of VASP for VUH.

“Stewardship and optimization of antimicrobial use will improve patient care and have the additional benefits of reducing length of stay, reducing or eliminating waste and increasing efficiency,” he said.

According to the Centers for Disease Control and Prevention (CDC), clinical studies indicate that 30 to 50 percent of antibiotics prescribed in hospitals are unnecessary or inappropriate. Antimicrobial stewardship programs arose as concern grew among consumers, physicians and public health authorities about widespread overuse and misuse of antibiotics contributing to antibiotic resistance.

Use of antimicrobials in U.S. children’s hospitals apparently has been declining since 2007. As data from Vanderbilt show, stewardship programs can help to speed this downward trend.

According to a new study in the Journal of the Pediatric Infectious Diseases Society, at Children’s Hospital over the 38 months that preceded VASP implementation, inpatient antimicrobial use decreased by 3.7 percent per year, a rate similar to the 3.4 percent decrease per year during the same period in children’s hospitals nationally. Following the start of antimicrobial stewardship at Children’s Hospital, the decrease grew to 11.1 percent per year, compared to a decrease of 5.6 percent per year across other U.S. children’s hospitals over the same period.

According to this study, about 60 percent of children currently admitted to freestanding children’s hospitals in the United States receive at least one dose of an antimicrobial during their admission.

“It’s not that VASP is saying we’re here to reduce antimicrobial resistance. Rather, we’re here to optimize therapy, hopefully with the major benefit of reducing resistance, which we know is a crisis,” Nelson said.

• VASP pharmacists and physicians monitor day-to-day antimicrobial use through clinical laboratory results and electronic health records. As apparent opportunities arise to change or adjust a patient’s antimicrobial therapy, VASP contacts the care team to learn more about the patient and supply information and suggestions as appropriate.

• VASP conducts surveillance and periodic internal reporting of antimicrobial use, looking for any patterns of misuse and bringing them to the attention of clinical services as needed.

• Under the authority of the Pharmacy and Therapeutics Committee, VASP has established a list of 25 antimicrobials that require approval from an infectious diseases specialist before an order can be executed. Many of these are newer broad-spectrum antibiotics.

• For testing and treatment of inpatients with certain infections, VASP writes guidelines for use across VUMC.

• VASP contributes oversight for the VUMC drug formulary, as well as for pharmacy processes pertaining to antimicrobials.

“We touch a lot of different areas of the Medical Center, and it’s one of the things I’m most proud of concerning the stewardship program, this interconnectedness with a lot of the different departments and divisions. In particular we collaborate heavily with Quality, Safety and Risk Prevention, and we work hand-in-hand with Infection Prevention,” Nelson said.

In collaboration with Quality, Safety and Risk Prevention, VASP has plans to establish more detailed surveillance of antimicrobial use, and to expand surveillance to VUMC outpatients. According to Banerjee, the greater part of antibiotic use occurs among outpatients.

U.S. antimicrobial stewardship is growing. A leading health care accreditor, the Joint Commission, has adopted stewardship standards, effective Jan. 1, 2017. And according to Nelson, the CDC is preparing to introduce regulations about usage reporting for antibiotics.

Joining Banerjee for VASP in Children’s Hospital are Jessica Gillon, Pharm.D., and Kathryn Garguilo, MSN, R.N.

Joining Nelson for VASP in VUH are Patty Wright, M.D., Gowri Satyanarayana, M.D., Matthew Greene, M.D., Whitney Jones, Pharm.D., and Pratish Patel, Pharm.D.

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