(Management Case Study) Meeting Antimicrobial Stewardship Goals Without Infectious Disease Resources During the COVID-19 Pandemic

Purpose: This case describes how our antimicrobial stewardship team developed a plan to meet the challenge of new antimicrobial stewardship goals set after losing our infectious disease physician in 2020 and experiencing increased antimicrobial use during the Covid-19 pandemic years of 2020 and 2021.

Methods: Total antibiotic days of therapy (DOT) per 100 patient days in all diagnosis related groups increased by 3% during the Covid-19 pandemic years of 2020 and 2021 at our facility.  In June of 2020, the infectious disease physician and antimicrobial stewardship program leader for the hospital resigned and has not yet been replaced.  The chief hospitalist physician and pharmacy clinical manager became the co-leaders of the antimicrobial stewardship program.  During the Covid-19 years of 2020 and 2021, no new goals were set for antimicrobial stewardship. In March of 2022, the antimicrobial stewardship team set two new goals for 2022 to be measured using the National Healthcare Safety Network antibiotic use module, expressed as DOT per 1000 days present (DP).  The first goal was a 5% reduction in total antibiotic use and the second was a 10% reduction in the use of gram-positive agents (vancomycin, linezolid, daptomycin, and ceftaroline).  A pharmacy department goal for pharmacist antimicrobial stewardship interventions was set in February 2022 at 100 per month.   The baseline period used for all goals was the 2021 monthly average. The antimicrobial stewardship team developed a multipronged approach to meet these goals which included education, empiric therapy guidelines, and pharmacist stewardship rounds.

Results: Education was provided to the pharmacists and the hospitalist group in addition to one on one education to key prescribers.  The content included current prescribing data, antimicrobial stewardship goals for 2022, and a review of appropriate therapy for pneumonia and skin and soft tissue infections.  Revised empiric therapy guidelines were also provided to the pharmacists and hospitalist group. Pharmacy antimicrobial stewardship rounding at least twice weekly was initiated with emphasis on reviewing streamlining opportunities for patients receiving gram-positive therapies.  For January through April 2022, the monthly average of total antibiotic use was 828 DOT per 1000 DP (goal of 750, baseline of 790) and gram-positive agent use was 147 DOT per 1000 DP (goal of 133, baseline of 148). However, in April, the first full month after the 2022 goals were set and the multipronged approach was fully implemented, total antibiotic use was 777 DOT per 1000 DP (goal of 750, baseline of 790) and gram-positive agent use was 124 DOT per 1000 DP (goal of 133, baseline of 148).  For January through April 2022, pharmacy antimicrobial stewardship interventions were 97 per month, and averaged 154 per month for March and April (goal of 100, baseline of 21).

Conclusion: A multipronged approach using education, empiric treatment guidelines, and pharmacy stewardship rounding and intervention in order to help meet utilization goals is an effective strategy in the absence of an infectious disease physician.