By Chris Cook, PharmD, Ph.D.
A group of researchers from Stanford University believes small hospitals in the U.S. need to focus on antibiotic stewardship, based on a research project that found hospitals with 200 beds or fewer were likely to have inconsistent efforts to reduce antibiotics overuse and misuse.
“Antibiotic use and misuse is driving drug resistance,” wrote the Stanford team of clinical epidemiologists. “Much of US healthcare takes place in small community hospitals (SCHs); 70% of all US hospitals have <200 beds. Antibiotic use in SCHs is poorly described. We evaluated antibiotic use using data from the National Healthcare and Safety Network antimicrobial use option from the Centers for Disease Control and Prevention.”
The CDC’s 2014 survey for the National Healthcare and Safety Network (NHSN)concluded that increasing hospital size is a major predictor of effective antibiotic stewardship. The NHSN survey showed that hospitals that met all of the CDC’s core elements for antibiotic stewardship were likely to be large community hospitals, or those with 200 beds and up. The 2014 NHSN showed that antibiotic stewardship programs and infectious diseases consultations are more common at large hospitals than at small ones.
The CDC’s NHSN is the most widely used healthcare-associated infection tracking system. NHSN also provides facilities, states, regions, and the nation with data needed to identify problem areas, such as ineffective antibiotic stewardship efforts. NHSN is used to measure progress of prevention efforts, and ultimately eliminate healthcare-associated infections and to promote effective antibiotic stewardship.
For the Stanford study, researchers focused on the Intermountain Healthcare System, which is a Utah-based, not-for-profit system of 22 hospitals, 1,600 physicians and advanced practice clinicians at about 180 clinics, a health plans division called SelectHealth. Within the system, there are 16 small and 4 large community hospitals. Data on antibiotic use was analyzed from 2011 to 2013 from the Intermountain electronic medical records system.
Antibiotic use in the small hospitals was similar to that of the large hospitals. Antibiotics use was measured as days of therapy per 1000 patient-days (DOT/1000PD). Total antibiotic use rates varied widely across the 15 SCHs (median, 436 DOT/1000PD; range, 134–671 DOT/1000PD) and were similar to rates in 4 LCHs (509 DOT/1000PD; 406–597 DOT/1000PD).
The antibiotic use rates also varied significantly by patient care unit within the small community hospitals. ICUs had the highest total antibiotic use and the highest rates of broad-spectrum usage. Miscellaneous units (which included labor and delivery, nursery, maternity, and psychiatry units) had the lowest antibiotic use rates and also the lowest rates of broad-spectrum usage; however, it should be noted that the proportion of patient-days in miscellaneous unit types was highly variable. Within medical-surgical units, categories 1 and 4 antibiotics predominated, and use of broad-spectrum antibiotics was less than that observed in the ICUs.
While antibiotic prescribing at small community hospitals did not vary greatly from the pattern seen at the large Intermountain hospitals, the researchers concluded that small community hospitals within the U.S. will face significant challenges meeting the three major antibiotic stewardship requirements:
- The National Action Plan for Combating Antibiotic-Resistant Bacteria
- The Joint Commission’s New Antimicrobial Stewardship Standard
- Centers for Medicare & Medicaid Services Hospital and Critical Access Hospital (CAH) Changes to Promote Innovation, Flexibility, and Improvement in Patient Care
The primary problem facing small hospitals is limited access to infectious diseases physician and/or pharmacist leadership as well as limited information technology support. The researchers believe there should be specific antibiotic stewardship guidance written for small community hospitals that reflects their unique needs. They also recommend continued research into the use of novel stewardship techniques and technologies; for example, stewardship and infectious disease telehealth consultations.
“Regardless of the challenges, given the high rates of antibiotic use and similar prescribing patterns compared with LCHs that we have described, implementing ASPs in SCHs is critical. The infectious diseases community must respond and assist SCHs in establishing effective ASPs to meet the needs of our patients and address antibiotic resistance,” concluded the researchers.
Opinions expressed in this article are not necessarily those of bioMérieux, Inc.
Christopher Cook, PharmD, Ph.D.
Christopher Cook has over 20 years’ experience in pharmacy practice ranging from academia to clinical practitioner and outcomes researcher. Dr. Cook is currently the Senior Director, Antimicrobial Stewardship Customer Support at bioMérieux, Inc.. He also serves on the National Quality Forum Patient Safety Committee. Prior to joining bioMerieux, Dr. Cook served as a Clinical Professor at the University Of Georgia College Of Pharmacy.
