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.

Education

  • Creation, maintenance and updating of BJH Tool Book
  • Educational presentations to BJH and WashU personnel and trainees
  • Leaders in antimicrobial stewardship training program

Monitoring and Reporting

  • Global antimicrobial usage at BJH
  • Targeted antimicrobial usage patterns of specific drugs, locations, patients, providers
  • Antimicrobial-associated adverse events
  • Scenarios requiring mandatory ID consultation

Interventions Aimed at Improving Antimicrobial Use

  • Restricted antimicrobial approval process
  • Prospective auditing and feedback for high risk antimicrobials and potentially inappropriate antimicrobial use scenarios
  • One-on-one antimicrobial stewardship case reviews (aka “handshake” stewardship)
  • EPIC clinical decision support design and oversight

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 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 on another. With repeated exposure, bacteria, fungi, and viruses all grow resistant to the antimicrobials we use to treat them. These resistant microbes then spread leading to harm that echoes forwards 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

Antibiotic Stewardship Team

PHYSICIANS

Kevin Hsueh, MD– Dr. Hsueh is the Medical Director of the Antimicrobial Stewardship Program at BJH, and the Chair of the BJC Anti-Infective Panel P&T Subcommittee. He is a board-certified ID physician with specialized training in leadership, patient safety, and quality improvement. He is an expert in antimicrobial stewardship interventions and assessment of antimicrobial use. Dr. Hsueh is also the Program Director for the CDC-sponsored national Leadership in Hospital Epidemiology, Antimicrobial Stewardship, and Public Health (LEAP) Fellowship run by the three ID professional societies IDSA, SHEA, and PIDS.

Michael Durkin, MD MPH– Dr. Durkin is a Co-Director of the Antimicrobial Stewardship Program at BJH. He is a board-certified ID physician and the Medical Director of Infection Prevention and Antimicrobial Stewardship at Barnes Jewish St. Peters and Progress West Hospitals. Dr. Durkin is highly experienced in studying outpatient antimicrobial use through clinical and administrative datasets. He has advanced training in administrative data, informatics, implementation science, and mixed methods research. Dr. Durkin has received research funding through the CDC, NIH, Missouri Department of Health and Senior Services, and Pew Charitable Trusts.

Sena Sayood, MD– Dr. Sayood is a board-certified ID physician and an Associate Medical Director for Antimicrobial Stewardship at BJH. He has particular expertise in engineering, software development, and electronic clinical decision support.

Miguel A. Chavez, MD MSc– Dr. Chavez is a board-certified ID physician working with the Division of Hospital Medicine and the BJH-ASP. His current focus is medical education and antifungal stewardship.

 

 

Michael “Josh” Hendrix, MD– Dr. Hendrix is a board-certified ID physician working with “steward pharmacists”

STEWARDHIP PHARMACISTS

Elizabeth Neuner, PharmD
 Elizabeth is a Board certified clinical pharmacist with PGY-2 ID residency training and has been practicing as an Infectious Diseases/Antimicrobial Stewardship Pharmacist since 2008.

Tamara Krekel, PharmD, BCPS, BCIDP  Tamara is a board certified pharmacotherapy specialist and infectious diseases pharmacist with PGY-2 ID residency training. She has been practicing as an Infectious Diseases/Antimicrobial Stewardship clinical pharmacy specialist since 2016.

Ed Casabar, PharmD, BCPS
 Ed is a board certified pharmacotherapy specialist with advanced training in infectious diseases and has been practicing as an Infectious Diseases clinical pharmacy specialist since 1987.

Dave Ritchie, PharmD
 Dave is a board certified pharmacotherapy specialist with advanced training in infectious diseases. He is also a Professor of Pharmacy Practice at the University of Health Sciences and Pharmacy in St. Louis.

 

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 in to the core ID curriculum for WashU ID Fellows.
  2. Stewardship Elective Rotations- A one-week rotation designed to give trainees a more 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 the full range of tools and experiences 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 housestaff 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 a 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.

Highlighted Publications

  1. Dunagan WC, Woodward RS, Medoff G, Gray JL, Casabar E, Smith MD, Lawrenz CA, Spitznagel E. A study of antimicrobial misuse in patients with posi­tive blood cultures. Am J Med 1989;87:253-259.
  2. Dunagan WC, Woodward RS, Medoff G, Gray JL, Casabar E, Lawrenz CA, Spitznagel E, Smith MD. Antibiotic misuse in two clinical situations: positive blood cultures and administration of aminoglyco­sides. Rev Infect Dis, 1991:13:405-412
  3. Bailey TC, Ritchie DJ, McMullin ST, Kahn M, Reich­ley RM, Casabar E, Shannon W, Dunagan WC. A randomized, prospective evaluation of an interven­tional program to discontinue intravenous antibiotics at two tertiary care teaching institutions. Pharmaco­therapy 1997;17(2):277-281.
  4. Hsueh K, Reyes-Angeles M, Krekel T, Casabar E, Ritchie D, Jafarzadeh SR, Lane MA, Hays A, Durkin MJ. Effective Antibiotic Conservation by Emergency Antimicrobial Stewardship During a Drug Shortage. Infect Control Hosp Epidemiol. 2017 Mar;38(3):356-359.
  5. Seidelman J, Dicks KV, Durkin MJ, Baker AW, Moehring RW, Anderson DJ, Sexton DJ, Chen LF, Lewis SS. Using Clinical Scenarios to Understand Preventability of Clostridium difficile Infections by Inpatient Antibiotic Stewardship Programs. Infect Control Hosp Epidemiol. 2017 Jun;38(6):747-749.
  6. Durkin MJ, Feng Q, Warren K, Lockhart PB, Thornhill MH, Munshi KD, Henderson RR, Hsueh K, Fraser VJ. An Assessment of Inappropriate Antibiotic Prescribing Among a Large Cohort of General Dentists in the United States. Journal of the American Dental Association. 2017 Dec;148(12):878-886.e1.
  7. Britt NS, Ritchie DJ, KollefMH, Burnham CA, Durkin MJ, Hampton NB, Micek ST. Clinical epidemiology of carbapenem-resistant Gram-negative sepsis among hospitalized patients: shifting burden of disease? American Journal of Infection Control. 2018 Mar 27;62(4).
  8. Britt NS, Ritchie DJ, KollefMH, Burnham CA, Durkin MJ, Hampton NB, Micek ST. Importance of Site of Infection and Antibiotic Selection in the Treatment of Sepsis Due to Carbapenem-Resistant Pseudomonas aeruginosa. Antimicrobial Agents and Chemotherapy. 2018 Mar 27;62(4).
  9. Durkin MJ, Jafarzadeh SR, Sallah YH, Hsueh K, Munshi KD, Henderson RR, Fraser VJ. Outpatient Antibiotic Prescription Trends in the United States: A National Cohort Study. ICHE. 2018 May;39(5):584-589.
  10. DurkinMJ, Keller M, Butler AM, Kwon JH, Dubberke ER, Miller AC, Polgreen PM, Olsen MA. An Assessment of Inappropriate Antibiotic Use and Guideline Adherence for Uncomplicated Urinary Tract Infections. Open Forum Infect Dis. 2018 Aug 10;5(9):ofy
  11. Durkin MJ, Hsueh K, Sallah YH, JafarzedhSR, Feng Q, Lockhart BP, Thornhill MH, Munshi KD, Henderson RR, Fraser VJ. An evaluation of dental antibiotic prescribing practices in the United States. Journal of the American Dental Association. 2018 Oct;46(10):1092-1096.
  12. Foong KS, Hsueh K, Bailey TC, Luong L, Iqbal A, Hoehner C, Connor L, Casabar E, Lane M, Burnett Y, Ritchie D, Krekel T, Newland H, Weilmuenster L, Heuring B, Durkin MJ, Hamad Y. A Cluster of Cefepime-induced Neutropenia during Outpatient Parenteral Antimicrobial Therapy. Clin Infect Dis. 2018 Dec 24. doi: 10.1093/cid/ciy1112.
  13. Thornhill MH, Dayer MJ, Durkin MJ, Lockhart PB, Baddour LM. Risk of Adverse Reactions to Oral Antibiotics Prescribed by Dentists. J Dent Res. 2019 Jul 17:22034519863645.
  14. Durkin MJ, Feng Q, Suda KJ, Lockhart PB, Thornhill MH, Warren K, Munshi KD, Henderson RR, Fraser VJ; Centers for Disease Control and Prevention Epicenters. Longitudinal antibiotic prescribing trends among US dental specialists within a pharmacy benefits manager, 2013 through 2015. J Am Dent Assoc. 2019 Oct;150(10):846-853.e5.
  15. Lockhart PB, TampiMP, Abt E, Aminoshariae A, Durkin MJ, Fouad AF, Gopal P, Hatten BW, Kennedy E, Lang MS, Patton LL, Paumier T, Suda KJ, Pilcher L, Urquhart O, O’Brien KK, Carrasco-Labra A. Evidence-based clinical practice guideline on antibiotic use for the urgent management of pulpal- and periapical-related dental pain and intraoral swelling: A report from the American Dental Association. J Am Dent Assoc. 2019 Nov;150(11):906-921.e12.
  16. TampiMP, Pilcher L, Urquhart O, Kennedy E, O’Brien KK, Lockhart PB, Abt E, Aminoshariae A, Durkin MJ, Fouad AF, Gopal P, Hatten BW, Lang MS, Patton LL, Paumier T, Suda KJ, Cho H, Carrasco-Labra A. Antibiotics for the urgent management of symptomatic irreversible pulpitis, symptomatic apical periodontitis, and localized acute apical abscess: Systematic review and meta-analysis-a report of the American Dental Association. J Am Dent Assoc. 2019 Dec;150(12):e179-e216.
  17. Thornhill MH, Dayer MJ, Durkin MJ, Lockhart PB, Baddour LM. Oral antibiotic prescribing by NHS dentists in England 2010-2017. Br Dent J. 2019 Dec;227(12):1044-1050.
  18. Marks LR, Liang SY, MuthulingamD, Schwarz ES, Liss DB, Munigala S, Warren DK, Durkin MJ Evaluation of partial oral antibiotic treatment for persons who inject drugs and are hospitalized with invasive infections. Clin Infect Dis. 2020 Apr 2:ciaa
  19. SayoodSJ, Venkatram C, Newland JG, Babcock HM, Warren DK, Turabelidze G, McKay VR, Rachmiel EC, Peacock K, Habrock-Bach T, Hsueh K, Durkin MJ. Experiences from the Missouri Antimicrobial Stewardship Collaborative: A mixed methods study [published online ahead of print, 2020 Aug 4]. Infect Control Hosp Epidemiol. 2020;1-3.
  20. Pinkerton M, Bongu J, James A, Lowder J, Durkin M. A qualitative analysis of diagnostic testing, antibiotic selection, and quality improvement interventions for uncomplicated urinary tract infections. PLoSOne. 2020;15(9):e Published 2020 Sep 2. doi:10.1371/journal.pone.0238453
  21. Thornhill MH, Gibson TB, Durkin MJ, Dayer MJ, Lockhart PB, O’Gara PT, Baddour LM. Prescribing of antibiotic prophylaxis to prevent infective endocarditis. J Am Dent Assoc. 2020 Nov;151(11):835-845.e31. doi: 10.1016/j.adaj.2020.07.021. PMID: 33121605.
  22. Carlsen DB, Durkin MJ, Gibson G, JurasicMM, Patel U, Poggensee L, Fitzpatrick MA, Echevarria K, McGregor J, Evans CT, Suda KJ. Concordance of antibiotic prescribing with the American Dental Association acute oral infection guidelines within Veterans’ Affairs (VA) dentistry. Infect Control Hosp Epidemiol. 2021 Mar 2:1-9. doi: 10.1017/ice.2021.16. Epub ahead of print. PMID: 33650474.
  23. Clark AW, Durkin MJ, Olsen MA, Keller M, Ma Y, O’Neil CA, Butler AM. Rural-urban differences in antibiotic prescribing for uncomplicated urinary tract infection. Infect Control Hosp Epidemiol. 2021 Feb 24:1-8.
  24. Butler AM, Durkin MJ, Keller MR, Ma Y, DharnidharkaVR, Powderly WG, Olsen MA. Risk of Antibiotic Treatment Failure in Premenopausal Women with Uncomplicated Urinary Tract Infection. Pharmacoepidemiol Drug Saf. 2021 Mar 30. doi: 10.1002/pds.5237. Epub ahead of print. PMID: 33783918.
  25. SayoodSJ, Botros M, Suda KJ, Foraker R, Durkin MJ. Attitudes Towards using Clinical Decision Support in Community Pharmacies to Promote Antibiotic Stewardship. Journal of the American Pharmacists Association 2021. Epub ahead of print.

Contact

The BJH-ASP can be contacted at BJH.ASP@email.wustl.edu or by reaching out to either of the following:

Kevin Hsueh, MD
Medical Director of BJH-ASP
Washington University Infectious Diseases
Kevin.Hsueh@wustl.edu

Elizabeth Neuner, PharmD
Antimicrobial Stewardship Pharmacist
BJH Pharmacy
Elizabeth.Neuner@bjc.org

Please note, communication with the BJH-ASP does not constitute a formal medical consultation unless otherwise specified, and should not be utilized for urgent medical concerns or questions.