File, Thomas M. Jr; Tan, James S.
Infectious Disease Section, Northeastern Ohio Universities College of Medicine, Rootstown and Summa Health System, Akron, OH.
Address correspondence and reprint requests to Thomas M. File Jr, 75 Arch St. Suite 105, Akron, OH 44304. E-mail: email@example.com.
The discovery of potent antimicrobial agents was one of the greatest contributions to medicine in the 20th century. Unfortunately, widespread increasing antimicrobial resistance among major pathogens has now compromised therapy of many patients in the hospital. While this bacterial resistance is increasing, unfortunately, new antimicrobial drug development in this arena is decreasing. Food and Drug Administration approval of new antibacterial agents decreased during the 20-year period from 1983 to 2002.1 In the face of growing antibacterial resistance, we must recognize the drivers of resistance and optimize principles for appropriate antimicrobial use so we can maintain the utility of drugs that we have now.
Antimicrobial resistance can increase the risk of therapeutic failure and superinfection; therefore, it raises the cost of health care. The increase in resistance is a result of several factors, but a major factor driving resistance is the overall volume of antimicrobial prescribing-particularly for indications that do not warrant such therapy. Potential solutions to assuring more appropriate use of antimicrobials within the hospital setting are the focus of the leading 2 original articles of this issue: the use of antimicrobial advisory teams and the use of clinical practice guidelines for community-acquired pneumonia (CAP).2,3
In the article by Kravitz et al, an antimicrobial advisory team comprised of 1 infectious disease (ID) physician and 2 clinical pharmacists led to significant improvement in antimicrobial usage. The most common recommendation by the team was discontinuation of intravenous (IV) antibiotics (in most cases because there was no evidence of bacterial infection). Other effective recommendations included change from IV to oral antibiotics and change to more effective empiric regimens. As the authors stressed, they sought to "improve rather than restrict antibiotic prescribing." They concluded that antimicrobial advisory teams "offer an efficient means to enhance patient safety, improve utilization of hospital resources, and possibly control antimicrobial resistance." Of importance to ID clinicians, the authors did not observe any deleterious effect on ID consultation.
Other studies have documented the benefit of the antibiotic advisory team approach.4-6 At our institution, we have been using a pharmacist-physician antibiotic support team (AST) which is similar to that described by Kravitz et al, since 2000.7 It was designed to improve patient care by modifying antimicrobial regimens. The AST program incorporated the experience, expertise, and support of the ID physicians who spent an average of less than 30 min/d in consultation regarding the AST patients. Before initiating the AST, the ID division and the department of pharmacy developed guidelines for an appropriate empirical choice of antimicrobials for a given working diagnosis. The guidelines were distributed to the AST's clinical pharmacist who evaluated patients who had begun IV antimicrobial therapy within 24 hours. The impact of the AST demonstrated a significant reduction in overall costs to the institution and was felt to have significantly improved the antimicrobial usage. The most common example of changes recommended for improved antimicrobial coverage included early change from IV to oral therapy, dose adjustment for patients with renal dysfunction, more appropriate antimicrobial choices for empiric therapy of specific working diagnoses, and appropriate change to tailored therapy based on the results of susceptibility tests from appropriate bacteriologic tests. In general, we found that this system was well received by the medical staff and did not have a deleterious effect on our number of consultations. If anything, it seemed to increase consults as individual members of the medical staff became aware of ID issues that had not been considered in the initial evaluation of the patient's care.
The second paper by Mazzola et al3 describes the experience of development and early implementation of a clinical practice guideline for CAP. A team of clinicians including ID, pulmonary, emergency room physicians, primary care internal medicine, as well as clinical pharmacists, a nurse practitioner, and case manager, developed a local clinical pathway based on the recommendations from national CAP guidelines at the time. The clinical pathway aimed to standardize the overall treatment of patients with a focus on the hospital and discharge decisions, appropriate antibiotic selection, and a patient stability criteria to assist physicians with the decision to switch from IV to oral antibiotics. It must be recognized that antimicrobials selected by this team were appropriate based on the national guidelines at the time but would be different if based on the most recent guidelines (especially for patients hospitalized to the general ward where a macrolide is now recommended to be always included for empiric therapy if a β-lactam is used).8
Because the evaluation of this study was during the early time period of implementation of the pathway, it is not surprising that less than hoped-for compliance was observed. Nevertheless, the authors felt that implementation and observed compliance of their pathway lead to changes, which the authors felt led to improved performance.
In general, clinical guidelines have been shown to improve medical practice.9 The use of clinical practice guidelines can be an effective means of changing behavior, such as promoting the appropriate use of antibiotics. Effective clinical guidelines should improve patient care while enhancing cost savings. However, cost savings should not be the primary motivating factor. Several studies have validated the benefit of treatment guidelines for CAP, showing improved outcomes in terms of cost, length of stay in the hospital, and mortality.10 Dean et al studied outcomes among 28,600 pneumonia patients over 5 years as a pneumonia guideline was being implemented in the Intermountain Health Care system.11 Mortality and other outcomes were compared before versus after implementation, with Utah patients treated by non-Intermountain Health Care-affiliated physicians serving as the concurrent control. Mortality at 30 days among hospitalized patients was 3.2% lower with the guideline, P = 0.035.
For guidelines to be of value, they should improve outcomes of patients. As indicated by Mazzola et al, the success of a guideline such as theirs will continue to require monitoring, reevaluation, and update. With their initial guideline, they did not have a preprinted order form for the CAP patients, but they suggested that this may be 1 method to improve compliance. For the past 10 years, our institution had adopted this strategy with our CAP clinical pathway, and we have observed significant improvement in appropriate antimicrobial usage, length of stay, and cost. We recommend the implementation of local clinical pathways based on evidence-based guidelines (such as developed by the Infectious Diseases Society of America) as another solution to assure appropriate antimicrobial use.
The involvement of ID physicians in programs, such as those described by Kravitz et al and Mazzola et al, places the ID clinical practitioners in a prominent role. We believe that a program such as this will continue to be a vital role in hospital infection control, antimicrobial utilization, and pharmacy expenditure. ID clinical practitioners who are involved in planning and implementation deserve adequate compensation and administrative support from their respective institution. We welcome comments from our readers concerning their own experience with similar or other programs. We anticipate publishing your input into a regular section, "Clinical ID Corner."
1. Spellberg B, Powers JH, Brass EP, et al. Trends in antimicrobial drug development: implications for the future. Clin Infect Dis
2. Kravitz GR, Bornstein PF, Khan MA. Implementation of an antibiotic advisory team at a private non-teaching hospital: expanding the role of the infectious disease specialist. Infect Dis Clin Prac
3. Mazzola JL, Schaefer OP, DeBellis RJ, et al. Evaluation of antibiotic usage with a local community-acquired pneumonia guideline. Infect Dis Clin Prac
4. Sunenshine RH, Liedtke LA, Jernigan DB, et al. Role of infectious diseases consultants in management of antimicrobial use in hospitals. Clin Infect Dis
5. Capelastegui A, Espana PP, Quintana JM, et al. Improvement of process-of-care and outcomes after implementing a guideline for the management of community-acquired pneumonia: a controlled before-and-after design study. Clin Infect Dis
6. Struelens MJ. Multidisciplinary antimicrobial management teams: the way forward to control antimicrobial resistance in hospitals. Curr Opin Infect Dis
7. Pasquale TR, Komorny KM, Letting-Mangira D, et al. A pharmacist-physician antibiotic support team. Pharm Ther
8. Mandell LA, Bartlett JG, Dowell SF, et al. Update of practice guidelines for the management of community-acquired pneumonia in immunocompetent adults. Clin Infect Dis
9. File TM Jr. Impact of guidelines on antimicrobial treatment of respiratory tract infections. In: Owens RC, Ambrose PG, Nightingale CH, eds. Antibiotic Optimization Through Innovative Programs, Guidelines and Formulary Considerations.
Marcel Dekker, Inc. NY. In Press.
10. Dean NC, Bateman KM. Local guidelines for community-acquired pneumonia: development, implementation, and outcome studies. Infect Dis Clin North Am
11. Dean NC, Silver MP, Bateman JB, et al. Decreased mortality following implementation of a treatment guideline for community-acquired pneumonia. Am J Med
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