More than half of patients in U.S. hospitals receive at least one antibiotic during their hospital stay; however, one-third of antibiotic prescriptions in hospitals involve potential prescribing problems, such as prescribing an antibiotic when it is not needed or giving an antibiotic for too long, according to the Centers for Disease Control and Prevention (CDC).
And, in hospitals, misuse of antibiotics can lead to the development of antibiotic resistance, which adversely affects morbidity, mortality, length of stay, and cost, the CDC reports.
A study, recently published in the Joint Commission Journal on Quality and Patient Safety, found that antimicrobial-resistant organisms account for more than two million infections and 23,000 deaths annually in the United States. Studies from diverse settings estimate that between 25 percent and 50 percent of antibiotic use in hospitals is sub-optimal or unnecessary. Hospital antimicrobial stewardship programs can reduce inappropriate antimicrobial use, length of stay, Clostridium difficile infection, rates of resistant infections and cost, the researchers concluded.
To combat the threat of antimicrobial resistance, The Joint Commission and the Centers for Medicare & Medicaid Services (CMS) have initiated or proposed requirements for hospitals to have antimicrobial stewardship programs, but implementation remains challenging, according to the above study, led by Shashi Kapadia, M.D., instructor of medicine, division of infectious diseases at Weill Cornell Medicine in New York City. As of 2014, only 39 percent of hospitals in the United States reported having a program that met all recommended elements of stewardship programs, and only 55 percent had any antimicrobial stewardship program infrastructure.
That study also examined top antimicrobial stewardship programs in U.S. hospitals and found that innovative programs are integrating IT systems to enable real-time interventions to optimize antimicrobial therapy and patient management.
At Penn Medicine, based in Philadelphia, clinical leaders have developed a robust IT system for stewardship to facilitate clinical decision support and identify opportunities for intervention. Penn Medicine, the University of Pennsylvania Health System, operates six hospitals in eastern Pennsylvania. The Hospital of the University of Pennsylvania is home to one of the oldest antibiotic stewardship programs in the country, as it was formed in 1992 by associate chief medical officer Neil Fishman, M.D., according to Keith Hamilton, M.D., associate healthcare epidemiologist and director of antimicrobial stewardship at the Hospital of the University of Pennsylvania.
Working with health technology company ILUM Health Solutions, the hospital’s antimicrobial stewardship team, led by Hamilton, initiated a project to leverage health IT to improve antimicrobial prescribing, with the aim of delivering decision support within clinicians’ workflow to help ensure the right patient gets the right antibiotic at the right time.
“If we were to choose an antibiotic that is too narrow for a given patient, too narrow spectrum, then we may not be treating their infection adequately, especially those with more severe infections, like sepsis. But, if we’re giving an antibiotic that is too broad spectrum, then we may be exposing the patient to unnecessary toxicity and side effects. Ultimately, our goal is to give an antibiotic that is effective but is not more than what a patient needs,” Hamilton says.
While the hospital had an established stewardship program infrastructure, Hamilton notes that there was room for improvement in antibiotic prescribing practices. “The existing solutions to antibiotic stewardship didn’t have an efficient approach to identifying the patients who may benefit from an improvement in their antibiotic treatments. Tracking antibiotic use on a healthcare system-level is also fairly challenging to do with current solutions,” he says.
ILUM Health Solutions, a Merck subsidiary, provides enterprise-wide disease management tools and services as well as assists with antimicrobial stewardship programs. Last fall, ILUM acquired Teqqa LLC, which provides precision analytics to help physicians assess what antibiotic to prescribe to patients. The Hospital at the University of Pennsylvania has been working with Teqqa since 2014, and Hamilton and his team saw an opportunity to leverage ILUM and Teqqa’s technologies to bring relevant data and lab results right to the point of care, within the clinicians’ workflow.
When the hospital first began working with Teqqa back in 2014, the antimicrobial stewardship team focused on creating software to track antibiotic use and resistance to help clinicians determine the resistance patterns in their given settings, Hamilton says. The team then focused on moving more toward a “precision medicine-type approach” using predictive models, and that software was implemented a year ago, he notes.
Keith Hamilton, M.D.
The platform integrates real-time electronic health record (EHR), lab and pharmacy data from across disparate systems, and can pull in vital signs, drug data, microbiology and other laboratory findings. And, ILUM has developed a series of alerts identifying patients that may need a change in antibiotics, Hamilton says. “These alerts can alert both us [antibiotic stewardship teams] as well as individual clinicians where a change may be warranted and we can make those interventions,” he says.