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Focus on QI for antimicrobial therapy to improve pneumonia treatment
Identify risks, treat aggressively, then pull back
Old habits in antibiotic prescribing add nothing to patient safety and health, while costing hospitals thousands of dollars each year, according to recent research involving health care-associated pneumonia (HCAP) and ventilator-associated pneumonia (VAP).
While improvements have been made in initial therapies and vaccinations, there remain some problems, experts say.
Hospitals have had lower mortality and improved outcomes among patients with pneumonia since the late 1990s, according to data from the National Pneumonia Project.1
"In 1995, the standard of care for management of pneumonia was to give patients a third-generation cephalosporin as monotherapy," says Dale Bratzler, DO, MPH, president and chief executive officer of the Oklahoma Foundation for Medical Quality in Oklahoma City, OK.
"But a variety of studies demonstrated that additional coverage of atypical organisms, such as legionella or mycoplasma, led to reduced mortality rates," Bratzler says.
In the 1998-2004 period, the 30-day mortality among pneumonia patients treated in hospitals dropped from 15.3% to 12.9%, Bratzler says.2
So now guidelines recommend that hospitals initially treat pneumonia patients with a cephalosporin plus a macrolide or provide fluoroquinolone therapy.3
This is why it's also important that hospital emergency department physicians screen patients for potential antibiotic resistance so they can be treated with an antibiotic drug cocktail rather than ineffective monotherapy, research suggests.1,4
But these therapies should not be prolonged past the recommended one-week time period unless there are clear medical reasons for doing so, additional research indicates.3
"The most important thing is to identify the risk factors that predispose patients to infection with unusual or multidrug-resistant pathogens," says Fredrick M. Abrahamian, DO, an associate professor of medicine at the University of California, Los Angeles, School of Medicine.
"These risk factors include, but are not limited to, immunocompromised patients and those with a recent history of hospitalization or prolonged intravenous antimicrobial therapy," Abrahamian says.
Other risk factors can include residence in a nursing home or history of ongoing hemodialysis.4
"Knowledge of these risk factors is important in the selection of initial empiric antimicrobial therapy," Abrahamian adds.
Patients should respond to treatment within three days and multiple-antibiotic therapy could continue for one week, but not for 2-3 weeks, the latest research suggests.
But what often happens is that physicians will keep patients on several antibiotics for weeks, even when lab results suggest that one or more of the initial treatments will provide no additional health benefit, says Rob Owens, PharmD, co-director of the antimicrobial stewardship program at Maine Medical Center.
"Instead of continuing the antibiotics for 14-21 days for infections such as hospital-acquired pneumonia [HAP], HCAP, or community-acquired pneumonia, which is excessive, we can continue for eight days or shorter," Owens says. "Good research shows it's as effective as 15 days in treatment for pneumonia."
By reducing the amount of time HCAP patients receive antibiotic treatment, clinicians are improving their outcomes by cutting the risk of adverse events, such as Clostridium difficile infection, as well as reducing resistance patterns, Owens adds.
The problem is that research demonstrating the benefits of a shorter treatment course is only a few years old, and many providers haven't changed their old habits, he notes.
"A lot of people don't know the research, and they feel comfortable with some other duration," Owens says. "The problem is that ignoring the data because you feel comfortable with some other duration ignores the harm that we're doing to our patients."
Also, the national guidelines provide no clear recommendation on how long antibiotics should be given, Bratzler says.
"I completely agree that appropriate antimicrobial stewardship calls for shortening the length of time for what is appropriate treatment for that patient," he says. "The guidelines address this concept, but don't provide formal recommendations that this is something you should measure as a measure of quality."
So the key is for hospital pharmacists to take the lead in a de-escalation of antibiotic use.
"It's critically important in the United States to reduce antibiotic resistance," Bratzler says. "And one factor is having patients on antibiotics for too long."
Also, clinicians need to use culture results to narrow the spectrum of antibiotics prescribed, as much as is possible, he adds.
The key to making these changes is to make antimicrobial stewardship a priority, the experts say.
Nationally, this can be done by holding providers accountable for various outcomes and sharing providers' results publicly, Bratzler says.
This has already been a chief reason why hospitals have vastly improved their vaccination programs for influenza and pneumonia, with numbers rising from 7.7% for pneumococcal vaccine in 1998 to 86.5% in 2008, Bratzler adds.
"We have lots of data now that when you nationally hold physicians and hospitals accountable for publicly reported standards of quality, it clearly drives performance and drives what they do," he adds.
Another way to improve antimicrobial stewardship is to start programs and dedicate staff and resources to these efforts.
For instance, Maine Medical Center's antimicrobial stewardship program has Owens and an infectious diseases (ID) physician team up to improve antibiotic use and safety.
"We each take a pile of antibiotic cases, collaborate, and talk about them," Owens says. "It's a fun thing to do because we each bring something different to the table."
When Owens and the ID physician first became a team, they went on rounds at the hospital to learn each other's habits and thought processes, he notes.
"It was less efficient, but we got on the same page about things, and now we've been doing it so long together that I know what she's going to say and she knows what I'm going to say, and we can act as one," Owens adds.
This synergistic antimicrobial stewardship team has helped Maine Medical Center improve patient care and save money.
"If you do the right thing, the cost savings is a side effect," Owens says. "These programs are in the worst-case scenario cost-neutral, and in the best case, you're saving lots of money."
The program saved between $100,000 and $200,000 in its antibiotic drug budget within one year of initiating the program, Owens says.
"When we benchmark ourselves to other hospitals of the same size, and look at antibiotic use per adjusted day, the antibiotic cost per day, and hospitalization rate, adjusted for census, then we fall within the top 5-10% among large organizations," Owens says. "We're a top performer."
And one compelling outcome of a particular study conducted at Maine Medical Center in patients with HAP and HCAP was the reduction of 124 unnecessary antibiotic days in a short, three-month period, according to outcomes from a QI project, Owens adds.
"Our post-antimicrobial stewardship program group needed a lot less antibiotics, and the outcomes were all the same," Owens explains. "So it showed that you can use less antibiotics effectively and safely."