Antimicrobial Stewardship

The Barnes-Jewish Hospital Antimicrobial Stewardship Program (BJH-ASP)

The Barnes-Jewish Hospital Antimicrobial Stewardship Program (BJH-ASP) is a formal arm of the hospital Patient Safety & Quality and Pharmacy Departments. Its mandate is to improve patient quality of care through the promotion of appropriate antimicrobial use. It is led by a specially trained group of infectious diseases physicians and infectious diseases/antimicrobial stewardship pharmacists. In 2018 BJH was recognized by the Infectious Diseases Society of America (IDSA) as an Antimicrobial Stewardship Center of Excellence.

Resources

The Barnes-Jewish Hospital Tool Book

The BJH-ASP created and maintains the Barnes-Jewish Hospital Tool Book. This online resource, available through web-browsers and through Apple and Android apps, is free for all users registering with an email from a qualifying domain (BJC, WUSTL, UHSP, SIUE, XULA). The Tool Book contains up-to-date information on hospital antimicrobial-related policies and procedures, treatment guidelines for common infections, infection prevention protocols, antimicrobial use monographs, and antibiograms. Links to the hospital’s formulary in Lexicomp and other drug information can also be found in the Tool Book.

Mobile Medical Applications

Several useful mobile medical applications are free for BJH and WashU personnel which can be of significant use in diagnosing and creating treatment plans for infectious diseases. In particular the following:

• Unbound Medicine/uCentral- Containing the Johns Hopkins Antibiotics Guide
• ClinicalKey- Contains Mandell, Douglas, and Bennett’s Principles and Practice of Infectious Diseases
• UpToDate- General resource for concise up-to-date summaries of the diagnosis and treatment of many medical/surgical diagnoses

Activities

The BJH-ASP performs a diverse array of activities in order to further the goal of improving antimicrobial use at BJH.

Stewardship at the Healthcare System Level

The BJH-ASP plays a leading role in antimicrobial stewardship initiatives across BJC HealthCare, the 13 hospital healthcare system that BJH belongs to. BJC HealthCare runs the Infectious Diseases-Antimicrobial Stewardship Program Collaborative (ID-ASP Collaborative), a monthly meeting where the stewardship programs can discuss issues at the various hospitals, share local interventions and plan larger initiatives, such as improving penicillin-allergy screening across the healthcare system. Additional system efforts involving stewardship are an antimicrobial-focused pharmacy and therapeutics subcommittee chaired and a meeting focused on improving antimicrobial-associated electronic clinical decision support. BJH-ASP members attend or chair all these meetings, accompanied by trainees that are interested in stewardship from a broader healthcare-network perspective.

Why is Antimicrobial Stewardship needed?

When they are needed, antimicrobials (antibiotics, antifungals) are critically life-saving medications, saving countless millions from morbidity and mortality. Yet, they are also one of the few types of medications where misuse of the drug on one patient, can actively lead to harm of another. After repeated exposure to the same drugs, bacteria and fungi are constantly finding new ways to avoid the effects of antimicrobials, subsequently not responding to the medications( (antimicrobial resistance) ed to treat the infections they cause. Antibiotic resistance is one of the greatest public health challenges of our time—few treatment options exist for people infected with antibiotic-resistant bacteria.

These resistant microbes then spread leading to harm that echoes forward to future patients leading to the scourge of antimicrobial resistant organisms (AROs) such as methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococcus (VRE), carbapenem-resistant enterobacterales (CRE), and extremely-drug resistant tuberculosis (XDR-TB) that the world faces today.

Reducing unnecessary usage of antimicrobials is the first step in slowing the development and spread of AROs. However, repeated studies have shown that between 12-50% of hospitalized patients and up to a third of outpatients receive antimicrobials inappropriately. This has fueled the increasing frequency and spread of AROs such as MRSA, VRE, CRE, and XDRO TB that have spread across the globe.  Additionally, antimicrobials are the number one causes of adverse drug events (ADEs) and their misuse has led to countless unnecessary injuries.

Antimicrobial stewardship exists to help medical providers reduce this unnecessary usage of antimicrobials in an era when antimicrobial agents and AROs continue to increase in complexity and difficulty.

Personnel

Training in Antimicrobial Stewardship

While clinical knowledge and expertise in the treatment of infectious diseases is vital for a leader of an antimicrobial stewardship program, the fact is that much of an antimicrobial steward physician and pharmacist’s job involves activities that are quite distant from the standard practice of clinical infectious diseases. For example:

• Designing and getting buy-in for quality improvement project proposals
• Querying and analyzing antimicrobial-associated data
• Recruiting champions and building leadership support for stewardship
• Assisting pharmacy formulary discussions on antimicrobials
• Reporting stewardship program activities and progress to hospital leadership
• Creating facility-specific guidelines and education
• Design/management of electronic decision support tools
• Administrative correction of problematic providers

The BJH-ASP works to train the next generation of physician and pharmacist antimicrobial stewards. Training is currently divided into 3 tiers:

1. Introductory Stewardship Lectures/Activities (for ID trainees)- To establish a baseline level of stewardship knowledge for all ID physician practitioners, stewardship is integrated into the core ID curriculum for WashU ID Fellows.
2. Stewardship Elective Rotations- A one-week rotation designed to give trainees an in-depth experience in antimicrobial stewardship, giving them exposure to a range of activities and endeavors being undertaken by the BJH-ASP.
3. Antimicrobial Steward Training Program- ID Fellows and Pharmacy Residents who voice an interest in future careers in antimicrobial stewardship are integrated directly into the BJH-ASP for one year. They are guided through the development of their own stewardship intervention/project and participate in the full range of stewardship activities. This training is meant to provide graduates with the full range of tools and experience necessary to become the leader of an antimicrobial stewardship program.

The History of Antimicrobial Stewardship at Barnes-Jewish Hospital

Barnes-Jewish Hospital was one of the first hospitals in the United States to implement a formal antimicrobial stewardship program. In 1985 the late Dr. Gerald Medoff, former Director of the Washington University Division of Infectious Diseases, and James L. Gray, PharmD, Director of Pharmacy, realizing the dangers of rapidly escalating utilization of broad-spectrum antimicrobials and the ensuing antimicrobial resistance, created what was then known as the Antibiotic Control Program (ACP).

The ACP was a joint effort of the Division of Infectious Diseases, Department of Pharmacy, and Program in Hospital Administration at Washington University School of Medicine.  The goal was to improve patient care by providing one-on-one teaching of house staff through interactions with infectious diseases. The ACP established several processes which would become the core of stewardship at BJH and at hospitals nation-wide.  The first was restriction of specific antimicrobials to Infectious Diseases providers. This would prevent excessive usage of last-line antimicrobials.  The second was what would eventually become known as prospective auditing. ID physicians and pharmacists would review the use of selected antimicrobials after they were ordered by other physicians in the hospital, to identify usage that was potentially inappropriate.

These two core stewardship activities, prospective auditing and antimicrobial restriction, continued to conserve and improve utilization of antimicrobials at BJH for many years.  However, rapid changes to many of the hospital’s fundamental care delivery systems in the mid-2000s (in particular the transition to computerized order-entry systems) necessitated a re-design and re-thinking of stewardship at BJH. In 2016 the BJH-ASP was formally re-incorporated in its current form under the Departments of Patient Safety and Quality, and Pharmacy. Its goal remains the same as when Dr. Medoff founded it, to improve the usage of antimicrobials, though in the current era it has grown significantly in terms of the number and sophistication of the interventions.