January 10, 2018
The University of Michigan Health System has infectious disease physicians and pharmacists in place to lead a multi-disciplinary program that promotes the appropriate use of antibiotics. The program’s overall success has attracted the attention of the Infectious Diseases Society of America, which recognized Michigan Health as an Antimicrobial Stewardship Center of Excellence.
Gregory Eschenauer, PharmD, a clinical pharmacist in infectious diseases at Michigan Health, is instrumental in empowering and engaging providers to choose and prescribe the right antibiotic at the right dose and for the right duration to improve patient outcomes.
He took a few minutes to discuss the pillars to Michigan Health’s antibiotic stewardship program, the serious issue of antibiotic resistance, and why it doesn’t make sense to optimize antibiotic use in the inpatient setting while inappropriate prescribing continues in outpatient clinics.
What are the inherent challenges to proper antimicrobial stewardship?
The sheer size of large, tertiary care academic centers presents one difficulty. We manage a 1,000-bed hospital where half of the patients receive an antibiotic on any given day. It’s a constant challenge to assess whether antibiotic use is appropriate and identifying patients who could benefit from the expertise of infectious disease pharmacists is problematic. In addition, most clinical practice guidelines contain recommendations that aren’t based on randomized controlled prospective trials or even on good retrospective studies. The guidelines are largely based on the opinions of experts. Patient volume and a lack of evidence for the antibiotic use we assess on a daily basis are the main obstacles we encounter.
How do you work to overcome those barriers?
Like most institutions, we implement a drug-based restriction approach, which involves the prospective authorization of the “big gun” antibiotics. We also monitor other antimicrobial agents that need to be assessed with greater scrutiny. These tier 2 drugs can be initiated without authorization, but we receive a daily list of patients who are on the restricted agents to ensure their use is appropriate upon initiation and during the course of treatment. Those categories don’t include the majority of antimicrobial use without our hospital, so we also use computerized decision support to target disease states and infections that we think could benefit from intervention and focused review. We assess how our antibiotic interventions in those areas improve process and outcomes measures.
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Why is it important to implement a multi-disciplinary effort among infectious diseases physicians and pharmacists?
Our goal is to empower pharmacists to disseminate our antibiotic administration guidelines and communicate with us when patient care isn’t going well. Infectious disease physicians and fellows also disseminate the guidelines and administration strategies that we espouse, and that’s a tremendous help. We rely on our pharmacists and physicians to help implement and recommend practices in accordance with our institutional practices and to educate staff about the evidence backing our recommendations. We also have clinical pharmacists of some caliber laying eyes on every patient every day. They review patient profiles and quickly assess if antibiotic use is appropriate. In addition, 4 to 5 adult infectious disease consult services see upwards of 80 patients a day. With those groups on board and continually updated, we’re able to maintain consistency in practice and optimize our antimicrobial stewardship efforts.
What benefits do infectious disease pharmacists bring to antimicrobial stewardship?
First and foremost, they obviously have expertise of content. But they must also have good communication skills because they interact with numerous physicians and surgeons on a daily basis. They need to be content experts to develop trust among physicians, but they must also be able to communicate their knowledge efficiently and effectively. That skill is essential and not focused on enough. Infectious disease pharmacists must also be strong project managers. They spend a lot of time developing and updating guidelines, meeting with leaders from various clinical service lines to troubleshoot patient care issues, and identifying and addressing recurrent issues and suboptimal practices.
Why is antimicrobial stewardship so critical in the current patient care climate?
When patients receive antibiotics they don’t need, they’re exposed to associated harms such as toxicities and allergies, and collateral damage such as Clostridium difficile infection, which has become more prominent in the last 10 to 15 years. We’ve arrived at a nearly post-antibiotic era. Some patients have 1 or 2 suboptimal treatment options left and are resistant to everything else. We’re doing a pretty good job of managing antimicrobial use in large academic hospitals, but it can be improved in smaller institutions. It’s certainly been neglected in community care settings, where the majority of antibiotic use occurs. As long as antibiotic use in the community continues to be suboptimal, we’re not going to reverse antibiotic resistance, regardless of how strictly we monitor antibiotic use in the hospital setting. We have to look at antibiotic use across all spectrums of care in order to truly manage the problem. That’s where the next generation of stewardship will focus.
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