Antimicrobial resistance is a global threat. In the U.S. alone, it affects more than 2 million people per year, killing more than 23,000 and adding $20 billion in healthcare costs. Reducing the overuse of antibiotics is an important patient safety and public health issue as well as a national priority.
We are at a critical juncture. We must take action before antibiotics of last resort are no longer effective.
Mitigating antimicrobial resistance is essential. If we apply the adage “you manage what you measure” to reducing antimicrobial resistance, we must measure antibiotic use effectively to reduce inappropriate over-utilization and to prioritize improvement efforts.
The good news is there are a number of ways we can measure use.
Measuring antimicrobial use
Measuring how antibiotics are used is essential to target interventions that optimize their use. It is important to measure:
- Overall hospital antibiotic use
- Specific antibiotics used
- Use by hospital location(s)
Antibiotic use can be measured as days of therapy (DOT), the sum of days an agent is administered, or defined daily dose (DDD). A World Health Organization measurement, DDD estimates antibiotic use by aggregating the number of grams (or fractions thereof) of each antibiotic purchased, dispensed or administered divided by the DDD.
Any debate about which of these methodologies may work best is beyond the scope of this post. However, regardless of methodology, benchmarking beyond your institution’s walls is critical to appreciating where your organization may have high variation in utilization.
CDC-NHSN antibiotic use module
As part of the National Healthcare Safety Network (NHSN), the Centers for Disease Control and Prevention (CDC) has developed an Antibiotic Use (AU) and Resistance Option that collects and reports monthly antimicrobial DOT data electronically. The module is available to facilities that have information systems capable of submitting electronic medication administration records and/or bar coding medication administration records using a Health Level 7 standardized clinical document architecture.
To participate in this option, work with your information technology staff to generate standard formatted file(s) that can be exported to the NHSN. Further, some electronic surveillance systems can assist with the submission of these data to the NHSN on a hospital’s behalf. As more facilities enroll in the option, the NSHN will begin to establish risk-adjusted facility benchmarks for antibiotic use.
Clinical outcomes resulting from antimicrobial stewardship interventions are an essential metric. For example, improving antibiotic use can have a significant impact on rates of hospital onset Clostridium difficile infections. This current challenge in many hospitals is an important target for antimicrobial stewardship programs. An advantage of this measure is that most acute care hospitals are already monitoring and reporting information on Clostridium difficile infections to NHSN as part of the Centers for Medicare and Medicaid Services Hospital Inpatient Quality Reporting Program.
Stewardship programs can result in significant direct drug cost savings and even larger savings when related costs are included. These savings have been helpful in garnering support for these programs. A recent CDC-Premier study found that eliminating most frequent redundant antimicrobial combinations would save U.S. hospitals more than $163 million or 2 percent of total hospital expenses. Consider comparing the difference in antibiotic costs before and after initiating a stewardship program.
Premier recently launched a new data-driven performance improvement collaborative of some 50 hospitals in 24 states that will apply stewardship insights from the Premier/CDC research published in October 2014.
To reduce antimicrobial resistance we must practice antimicrobial stewardship, and to effectively practice antibiotic stewardship we must measure antimicrobial use. As we face this crisis, we know the core elements for a hospital antimicrobial stewardship program. We have a measure that can be reported to NHSN that will allow us for the first time to develop national picture of antibiotic use in hospitals and to provide needed benchmarks to help prioritize interventions.
We are interested in your thoughts about enhancing antimicrobial stewardship efforts. Please share below.
CDC has developed a comprehensive checklist of Core Elements of Hospital Antibiotic Stewardship Programs as well as resources and tools for monitoring and assessing appropriate antibiotic prescribing; recommended general and pharmacy-led interventions; and methods and tools for measurement of antibiotic use, outcomes and resistance.
The Premier Safety Institute® includes a comprehensive website on antimicrobial stewardship.