Future plans will include developing a mentored implementation program in which SHM will provide guidance for hospitalists who want to develop or improve a stewardship program at their hospital. The guidance will be based in part on the CDC’s “Core Elements of Hospital Antibiotic Stewardship Programs,” a kind of guidebook on antibiotic stewardship.1
Read more about antibiotic stewardship resources.
Eric Howell, MD, SFHM, director of the collaborative inpatient medicine service at Bayview, associate professor of medicine at Johns Hopkins University School of Medicine, and CHII’s senior physician advisor, says it’s time for hospitalists to take on a bigger role.
“Doing ‘just in case’ antibiotics is really not appropriate and should be strongly discouraged, unless the risks are very high for a specific patient,” he says. A past president of SHM, Dr. Howell has long advocated that hospitalists take the time to explain the risk of excessive antibiotic use to their patients, even on a busy day.
“It’s our duty as physicians to make sure our patients get the best care possible, and often that means the physicians themselves have to do the educating,” he says. “I would say that, in general, it doesn’t take that much time. Having a conversation with your patient to educate them about anything—heart failure, diabetes, appropriate antibiotics—must be built into the care that we provide our patients somehow.”
That communication doesn’t necessarily have to be performed by the hospitalist, he notes. The pharmacist, nurse, or written material can relay this information. But somewhere along the line, he says, the antibiotic education must happen.
SHM’s initiative should help, simply because “knowledge is good,” says Dr. Zenilman, the ID expert at Hopkins Bayview. Key to success, he says, will be what happens when hospitalists are taking care of a patient—will they actually be willing to cut their regimens?
“People overuse antibiotics, sometimes not out of education issues, but because they’re anxious,” Dr. Zenilman says. “The more challenging part is getting people to deal with the uncertainty and recognizing intuitively that overuse has enormous complications.”
The literature is now replete with studies showing how antibiotic stewardship measures help curb resistance, eliminate incorrect antibiotic prescribing, lower antibiotic use, and lower costs.
A web-based program was projected to save almost $400,000 a year linked to restricted antibiotic use at Johns Hopkins, according to a 2008 study.2
In Canada, according to a 2007 study, a program including recommendations for alternative drugs and shorter, guideline-based treatment durations helped reduce Clostridium difficile infections by 60% over a two-year period.3
An analysis published in August, using data from the CDC’s National Healthcare Safety Network and Emerging Infections Program, concluded that a nationwide infection control and antibiotic stewardship intervention could, over five years, avoid an estimated 619,000 hospital-acquired infections from carbapenem-resistant Enterobacteriaceae, multidrug-resistant Pseudomonas aeruginosa, invasive methicillin-resistant Staphylococcus aureus (MRSA), or C. diff.4
In spite of the evidence, preliminary results of a recent SHM survey on antibiotic stewardship found very little support, in terms of money and protected time, for hospitalists to be involved in antibiotic stewardship programs.
UM’s Success Story
A kind of microcosm of what is possible can be seen at the University of Michigan. There, Scott Flanders, MD, MHM, clinical professor of internal medicine and past president of SHM, has led an effort, along with the CDC and the Institute for Healthcare Improvement, to look at hospitalist-led interventions for smarter antimicrobial use.
Having a conversation with your patient to educate them about anything—heart failure, diabetes, appropriate antibiotics—must be built in to the care that we provide our patients somehow. —Eric Howell, MD, SFHM, CHII senior physician advisor, director, collaborative inpatient medicine service, Johns Hopkins Bayview Medical Center, associate professor of medicine, Johns Hopkins University School of Medicine, Baltimore