According to the CDC, 20-50% of all antibiotics prescribed in U.S. acute care hospitals are either unnecessary or inappropriate. Like all medications, antibiotics have serious side effects, including adverse drug reactions and Clostridium difficile infection (CDI). The misuse of antibiotics has also contributed to the growing problem of antibiotic resistance, which has become one of the most serious and growing threats to public health (Huttner A, Harbarth S, Carlet J, et al. Antimicrobial resistance: a global view from the 2013 World Healthcare-Associated Infections Forum. Antimicrobial resistance and infection control. Nov 18 2013;2(1):31).
The CDC estimates more than two million people are infected with antibiotic-resistant organisms, resulting in approximately 23,000 deaths annually.
The CDC states that a growing body of evidence demonstrates that hospital based programs dedicated to improving antibiotic use, commonly referred to as “Antibiotic Stewardship Programs (ASPs)”, can both optimize the treatment of infections and reduce adverse events associated with antibiotic use. In 2014 CDC recommended that all acute care hospitals implement Antibiotic Stewardship Programs
Summary of Core Elements of Hospital Antibiotic Stewardship Programs
- Leadership Commitment: Dedicating necessary human, financial and information technology resources
- Accountability: Appointing a single leader responsible for program outcomes. Experience with successful programs show that a physician leader is effective
- Drug Expertise: Appointing a single pharmacist leader responsible for working to improve antibiotic use.
- Action: Implementing at least one recommended action, such as systemic evaluation of ongoing treatment need after a set period of initial treatment (i.e. “antibiotic time out” after 48 hours)
- Tracking: Monitoring antibiotic prescribing and resistance patterns
- Reporting: Regular reporting information on antibiotic use and resistance to doctors, nurses and relevant staff
- Education: Educating clinicians about resistance and optimal prescribing
The Joint Commission’s new Medication Management standard MM.09.01.01, effective January 1, 2017, requires accredited hospitals and critical access hospitals to address antimicrobial stewardship. As part of this new standard, TJC recommends that organizations base their antimicrobial stewardship program on the Centers for Disease Control and Prevention’s “Core Elements of Hospital Antibiotic Stewardship Programs.”
According to the CDC, antibiotics are often started empirically in hospitalized patients while diagnostic information is being obtained. However, providers often do not revisit the selection of the antibiotic after more clinical and laboratory data (including culture results) become available. An antibiotic “time out” prompts a reassessment of the continuing need and choice of antibiotics when the clinical picture is clearer and more diagnostic information is available.
The CDC recommends that all clinicians perform a review of antibiotics 48 hours after antibiotics are initiated to answer these key questions:
- Does this patient have an infection that will respond to antibiotics?
- Laboratory data will confirm the answer to this question
- If so, is the patient on the right antibiotic(s), dose, and route of administration?
- Can a more targeted antibiotic be used to treat the infection (de-escalate)? How long should the patient receive the antibiotic(s)?
The antibiotic time out allows the clinician a moment to pause and reassess antibiotic therapy. Because it is conducted when laboratory results are available clinicians will have a fuller clinical picture and can adjust antibiotic therapy as needed.