If Not Now, When? Seizing the Moment for Antibiotic Stewardship

Abstract

Affiliation: 1. Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. Received November 16, 2012; accepted November 21, 2012; electronically published December 19, 2012. 2012 by The Society for Healthcare Epidemiology of America. All rights reserved. 0899-823X/2013/3402-0002$15.00. DOI: 10.1086/669228 Efforts to improve antibiotic use in hospitals are consistently hampered by the complexity of medical decision making surrounding antibiotic administration. In addition to the myriad factors that influence a decision to start ntibiotics in the first place, there are a variety of issues that might change frequently during a course of therapy that can impact the decision to continue, change, or stop antibiotics. There is certainly a great need to improve the way clinicians make decisions to start antibiotics. Better education and availability of information at the point of care on optimal diagnosis and treatment of infectious syndromes and on antibiotic spectra and dosing will lead to more effective decisions on the initiation of antibiotics. Interventions at the time of antibiotic prescribing using decision support or prior approval programs have proven highly effective in improving the way we start antibiotics. Just as important as the decision to start antibiotics is the decision to continue them. Antibiotics are often started in settings where their utility is unclear. Hence, the need for continued antibiotic therapy needs to be regularly reassessed in light of ever-changing clinical information. At least it should. Too often, antibiotics are started and simply continued without critical reappraisal. One excellent strategy for improving reexamination of antibiotic treatments is to define specific moments when changes in therapy are especially likely to be important. This is a lesson learned from the World Health Organization hand hygiene campaign. Rather than simply telling people to clean their hands, the Clean Hands Campaign developed the My 5 Moments for Hand Hygiene approach, which lays out specific times during patient care when hand hygiene is especially critical. Essential to applying this approach to antibiotics is, of course, the definition of these key moments in antibiotic therapy. Given that microbiologic results are perhaps the single most important determinant of optimal antibiotics, a critical reassessment of therapy after 2 or 3 days, when culture results are likely to be available, seems warranted whenever antibiotics are used in hospitals. This has led to the concept of an “antibiotic time-out,” much like the procedure time-outs that have become standard practice before surgery. The idea is to pause and review a patient’s antibiotics after 2 or 3 days in light of not just the culture results but also the clinical response and other information that was not available when the antibiotics were started. In addition to an antibiotic time-out after 2 or 3 days of treatment, there are other key moments when an antibiotic time-out is warranted, as demonstrated in the article by Shaughnessy et al in this issue of Infection Control and Healthcare Epidemiology. In this excellent study, investigators from the Minneapolis Veterans Affairs Medical Center examined antibiotic therapy in patients with a new diagnosis of Clostridium difficile infection (CDI). Treatment guidelines for C. difficile emphasize the importance of evaluating and stopping all unnecessary antibiotics as a key part of treatment. Indeed, as the authors of this study point out, nonCDI antibiotics not only lower cure rates for CDI but also can increase the risk of disease recurrence. Shaughnessy and colleagues reviewed charts of patients who had a new diagnosis of CDI to see how often these patients were receiving unnecessary antibiotics. Each chart was reviewed by 2 infectious disease specialists, and necessity of therapy was based on whether the patient had an infection that required an antibiotic. In cases where an antibiotic was deemed necessary, the duration of therapy was also reviewed. The primary outcome was the total number of unnecessary antibiotic days. Their findings, while discouraging, do point out a critical opportunity for improvement. More than half (57%) of all patients with a new diagnosis of CDI received a non-CDI antibiotic at some point in the month following the CDI diagnosis. Of these 141 patients, only 23% (33) received fully optimal non-CDI antibiotic treatment, meaning they received no unnecessary doses of antibiotics. The vast majority of patients, 76%, received at least 1 unnecessary dose of an antibiotic. But most importantly, 36 of the 141 patients—or 26%—received only unnecessary antibiotics following a new diagnosis of CDI. Of the 2,147 antimicrobial days that occurred during a CDI and the 30 days following CDI treatment,