Antibiotic Stewardship Programs: A Multi-Modal Approach

February 13, 2017

Antibiotic Stewardship Programs: A Multi-Modal Approach

Antibiotic Stewardship Programs (ASP) are designed to optimize antibiotic utilization in order to reduce over-use, and the associated emergence of pathogen resistance. However, too often ASP programs are limited to review of appropriateness of antibiotics being administered. A multimodal approach could support more optimal antibiotic use.

Rapid diagnostics: Transitioning from traditional bacterial culture to rapid diagnostic tests can reduce the frequency of administering inappropriate antibiotics by expediting pathogen identification, and targeting treatment.  These tests are increasingly replacing traditional bacterial culture in hospitals across the country. Rapid molecular testing has been shown to improve timeliness of test results compared to standard testing and rapid phenotypic techniques have been shown to expedite targeted antibiotic therapy1. 

Reduce false positive cultures:  Outside of the lab, there are also efforts being made that support ASP programs.  For instance, reducing inappropriate urine and blood cultures has been show to directly reduce antibiotic use2.  False positive blood cultures can lead to patient harm as a result of administering antibiotics that are not needed.  This harm can include increasing the risk of Clostridium difficile infection (CDI) with the associated increased length of stay, cost and human suffering. Of course, it also includes contributing to continually emerging pathogen resistance to antibiotics. Practices to reduce false positive blood cultures include prepping skin and blood culture bottle tops with chlorhexidine alcohol solution.  Patient bathing with chlorhexidine has also been shown to reduce blood culture contamination rates.

False positive or inappropriate urine cultures can result in the same type of adverse events, including unnecessary antibiotics with the associated contribution to resistance, and increasing patient risk of acquiring CDI with the associated cost of hospital stay and patient suffering.  Genital cleaning with chlorhexidine has been shown to reduce urine culture contamination7. Additional efforts aimed at reducing inappropriate urine cultures include re-evaluating order sets that include unnecessary urine cultures, nursing education, and physician education.

Antiseptics in place of antibiotics. Some operating rooms are switching from reconstituted IV antibiotics for irrigation to sterile antiseptic (.05% chlorhexidine) irrigation solution for high risk surgical procedures such as orthopedic and cardiac3.  There is no solid evidence that antibiotic irrigation solution is effective, nor that IV antibiotic solution works topically.  The recently updated WHO SSI guidelines state “Do not use antibiotic incisional wound irrigation before closure for preventing SSI”.4

In addition, when nasal decolonization is being used to reduce infection risk of all types, antiseptics (alcohol or iodine based) are being used in place of mupirocin in many locations.5 This increasing use of nasal antiseptics serves to support reducing antibiotic (mupirocin) use and the reported emergence of mupirocin resistance.  Nasal antiseptics such as Nozin® Nasal Sanitizer® antiseptic, and the iodine nasal antiseptic products by 3M and Clorox are being used to effectively support reduction of surgical infections, device associated infections, and to reduce the incidence of contact isolation6,7.  In addition to efficacy, another benefit of nasal antiseptics is that they are designed to be applied immediately prior to the surgical procedure to reduce SSI risk, instead of by the patient for 5 to 7 days prior to the procedure.  This eliminates the challenge of patient compliance with self-administration of mupirocin.  They are also reported to be well tolerated by patients and easy to apply by staff, where they are used as part of daily decolonization protocol in some intensive care units, or to reduce the need for contact precautions for MRSA colonized patients.

Enhancing ASP programs with a multimodal approach may enable US healthcare to achieve faster results in optimizing antibiotic utilization and reducing/reversing the rate of emerging bacterial resistance to antibiotics.

 

  1. Buehler SS,Madison B, Snyder SR, Derzon JH, Cornish NE, Saubolle MA, Weissfeld AS, Weinstein MP, Liebow EB, Wolk DM. Effectiveness of Practices To Increase Timeliness of Providing Targeted Therapy for Inpatients with Bloodstream Infections: a Laboratory Medicine Best Practices Systematic Review and Meta-analysis. Clin Microbiol Rev. 2016 Jan;29(1):59-103.
  2. Mullin KM, Kovacs CS, Fatica C, Einloth C, Neuner EA, Guzman JA, Kaiser E, Menon V, Castillo L, Popovich MJ, Manno EM, Gordon SM, Fraser TG. A Multifaceted Approach to Reduction of Catheter-Associated Urinary Tract Infections in the Intensive Care Unit With an Emphasis on "Stewardship of Culturing". Infect Control Hosp Epidemiol. 2017 Feb;38(2):186-188.
  3. Edmiston CE Jr, Leaper DJ. Intra-Operative Surgical Irrigation of the Surgical Incision: What Does the Future Hold-Saline, Antibiotic Agents, or Antiseptic Agents? Surg Infect (Larchmt). 2016 Dec;17(6):656-664.
  4. WHO SSI Prevention Guidelines 2016 http://www.who.int/gpsc/ssi-prevention-guidelines/en/
  5. Septimus EJ, Schweizer ML. Decolonization in Prevention of Health Care-Associated Infections. Clin Microbiol Rev. 2016 Apr;29(2):201-22.
  6. Lee, B.Y., Bartsch, S.M.,Wong, K.F., Miller, L.G., Huang, S.S. Beyond the Intensive Care Unit (ICU): Countywide impact of universal ICU Staphylococcus aureus decolonization. American Journal of Epidemiology 2016. Mar 1; 183(5):480-9.
  7. Deatherage N, Impact of Reduced Isolation and Contact Precaution Procedures on Infection Rates and Facility Costs at a Non-Profit Acute Care Hospital. American Journal of Infection Control, Volume 44 , Issue 6 , S101 - S102.
  8. Selek MB1, Bektöre B, Sezer O, Kula Atik T, Baylan O, Özyurt M. Genital region cleansing wipes: Effects on urine culture contamination.   J Infect Dev Ctries. 2017 Jan 30;11(1):102-105.


© 2004-2017 Global Life Technologies Corp. All rights reserved. Nozin® Nasal Sanitizer® antiseptic is an OTC topical antiseptic drug and no claim is made that it has an effect on any specific disease.