Why We Need to Be Antimicrobial Stewards

Antibiotics are the most common prescription drugs given to children. In the United States, more than 60% of hospitalized children receive antibiotics, and roughly 75 million antibiotic prescriptions are given to children each year in the ambulatory setting, accounting for one-fourth of all medication use in this age group.

Unfortunately, antibiotic use isn’t always appropriate. Sometimes, this is because antibiotics are prescribed for conditions for which these drugs are not indicated, such as for viral infections. Other times, children receive the wrong type of antibiotic, the wrong dose, or the wrong duration of therapy.

Inappropriate prescribing of antibiotics is problematic because antibiotics have risks – and if prescribed unnecessarily, can lead to avoidable patient harm. More than 140,000 emergency department (ED) visits occur annually in the United States for antibiotic-related adverse effects, comprising almost 20% of all ED visits for drug-related adverse effects. In fact, rates of antibiotic-related adverse events were 3 times higher than rates of adverse drug events attributable to the most high-risk medicines, including anticoagulant and antiplatelet agents (eg, aspirin and clopidogrel), oral hypoglycemics (eg, metformin), and narrow therapeutic index agents (eg, phenytoin and lithium).

In addition to this direct patient harm, the public health implications of inappropriate antibiotic use are profound. Antibiotic overuse is the key driver of antibiotic resistance, which has been described by the World Health Organization (WHO) as “1 of the 3 greatest threats to human health.” The good news is that because of antibiotic stewardship and infection prevention and control efforts, the prevalence of some antibiotic resistant bacteria have decreased in recent years. However, the prevalence of others has increased, with over 2.8 million antibiotic resistant bacterial infections annually and over 35, 000 deaths. Further, infections with resistant bacteria  increase the cost of medical care; in the United States, we spend between $21 billion and $34 billion per year to treat antibiotic-resistant infections.

So What Can We Do?

Individual providers should always strive to make the best decisions regarding antibiotic prescribing for individual patients. Consider using the Agency for Healthcare Research and Quality (AHRQ) “Four Moments” Questions:

1. Does my patients have an infection that requires antibiotics?
2. Have I ordered appropriate cultures before starting antibiotics? What empiric therapy should I initiate?
3. A day or more has passed. Can I stop antibiotics? Can I narrow or change from IV to oral therapy?
4. What duration of antibiotic therapy is needed for my patient’s diagnosis?

In addition, implementation of an antimicrobial stewardship programs (ASP) is now required by The Joint Commission for acute care hospitals, and in 2019, became a Centers for Medicare and Medicaid Services (CMS) Condition of Participation. Expansion of stewardship activities to ambulatory surgery centers, dialysis centers, nursing homes and other long-term care facilities, and the ED, urgent care and outpatient settings is also recommended. The need for uniquely designed stewardship activities for virtual platforms and telehealth settings is an emerging area of investigation, and is particularly timely given the rise in use of these platforms during the COVID-19 pandemic.

What Is an Antimicrobial Stewardship Program?

Simply put, ASPs are designed to optimize antimicrobial prescribing through coordinated interventions designed to promote the selection of the optimal drug regimen. This includes the right drug, dose, duration, and route of administration. The benefits of ASPs include improved patient outcomes, including shorter hospital length of stay; reduced adverse events such as Clostridiodes difficile infection (CDI), drug reactions, and complications of central lines; improvement in rates of antibiotic susceptibilities to targeted antibiotics; and substantial cost savings.

CHOP's Antimicrobial Stewardship Program

CHOP was one of the first children’s hospitals to build and implement an ASP, created by Paul Offit, MD, Theo Zaoutis, MD, MSCE, and Talene A. Metjian, Pharm.D. over 2 decades ago. The ASP, housed in CHOP’s Center for Healthcare Quality and Analytics. (CHQA), consists of 2 medical directors, 2 infectious diseases-trained clinical pharmacists, and 9 pediatric infectious diseases fellows. This core team works closely with and relies on the support of several clinical groups — including the Division of Infectious Diseases, the Infectious Diseases Diagnostic Laboratory. (IDDL), CHOP data and analytics, nursing, pharmacy, and Infection Prevention and Control — to optimize antimicrobial use across the institution. In addition, the CHOP ASP also receives critical support from hospital executive leadership, which has provided the resources necessary to conduct a comprehensive ASP in one of the largest children’s hospitals in the nation. Without this collaboration and investment, the ASP could not be successful.

The CHOP ASP leverages a variety of guideline-recommended strategies to help improve antimicrobial use. It also constantly seeks to develop new partners for improving antimicrobial use across the institution, building upon successful initiatives led by physicians, pharmacists, nurse practitioners, and nurses in the PICU, NICU, oncology, hematology, emergency department, primary care, and across many surgical divisions, to name a few.

Examples of our multifaceted program include:

• Electronic health record-facilitated prior authorization for broad-spectrum antimicrobials reserved for severe or life-threatening infections
• Mandatory durations of antibiotic therapy for most restricted antimicrobials
• Support of a variety of clinical pathways for conditions requiring antimicrobial use
• Surveillance of all positive microbiologic cultures to ensure selection of optimal antibiotic therapy for invasive bacterial infections 
• Review of opportunities for IV to PO conversion of select antimicrobials
• Education of frontline providers regarding ASP initiatives and the importance of judicious antibiotic prescribing
• Antimicrobial drug expertise

In closing, antimicrobials are a precious resource that can be life-saving. It is our collective responsibility to preserve the future effectiveness of these drugs by prescribing them judiciously now. Please join the CHOP ASP in committing to prescribing the right antimicrobial at the right time at the right dose for the right duration.

Referral Information

For information or to refer a patient to the Division of Infectious Diseases, call 267-425-3377. Information can be found at www.chop.edu/infectious-diseases.

The Vaccine Education Center at CHOP has a wealth of information for physicians and patient families. Please visit vaccine.chop.edu for information on all vaccines and for resources to use with families (print materials, videos, mobile app and more).