Infectious disease fellow Theodore Markou starts each workday reviewing a list of patients with tests that are positive for Clostridium difficile, a bacterium that can cause an infection that produces toxins leading to severe diarrhea.
Most cases of C. diff occur as a result of taking antibiotics. While antibiotics kill the bacteria causing an infection, they also inflict collateral damage on the good bacteria that live in the intestine, allowing the C. diff bacteria to proliferate. As leader of the C. diff Action Team, Markou investigates every reported case at The Johns Hopkins Hospital. The team, which consists of specialists in antimicrobial stewardship and infection prevention, works with clinical teams to optimize care and ensure that precautions are in place to prevent the spread of C. diff.
“We go right to the unit and meet with the care team,” says infectious disease physician Sara Cosgrove, director of The Johns Hopkins Hospital’s Antimicrobial Stewardship Program. “We respect the team’s opinion and clinical judgment, but we also want to say, ‘Your patient got C. diff, and maybe it could have been prevented.’ Then, we discuss what we can do together to make sure the patient gets the best treatment and that C. diff doesn’t get spread to other patients.”
A New Joint Commission Mandate
Antibiotics are lifesaving drugs that have transformed medicine. However, their use comes with some risk. In addition to causing C. diff, they are associated with other side effects, such as kidney dysfunction, rashes and emergence of resistant bacteria. As much as 50 percent of prescribed antibiotics are suboptimal or not needed, according to the Centers for Disease Control and Prevention. This widespread overprescribing has resulted in a worldwide public health threat caused by antibiotic-resistant bacteria.
On Jan. 1, a new mandate from The Joint Commission requires that all hospitals implement an antimicrobial stewardship program aimed at optimizing antibiotic prescriptions. Already compliant, The Johns Hopkins Hospital’s program has been providing international leadership in this area for more than 15 years. Johns Hopkins Bayview Medical Center has been using The Johns Hopkins Hospital’s stewardship guidelines for many years. Like other Johns Hopkins member hospitals, it is now implementing its own stewardship program.
Collaborating with clinicians, the Johns Hopkins Hospital stewardship team introduced its first Antibiotics Guidelines handbook in 2002. Designed to fit in the pocket of a white coat, the now 168-page booklet provides extensive guidance on when to prescribe antibiotics, what kind to prescribe, what dose and for how long. The guide is updated annually and provided to all physicians, nurse practitioners, physician assistants, pharmacists, and third- and fourth-year medical students. New hires also receive training on Johns Hopkins’ best practices for prescribing.
A Bigger Role for Pharmacy
Another anchor of the stewardship program is that prescribing broad-spectrum antibiotics here requires a prior approval from a clinical pharmacist or infectious disease specialist. Approvals are granted during morning rounds or through a request to the on-call pagers. The stewardship team also reviews antibiotic use after a patient has been on therapy for two to three days, then discusses its findings with care teams. Often, these conversations result in a more targeted antibiotic being prescribed or a different treatment.
Infectious disease pharmacist Edina Avdic notes that the stewardship team is responsible for looking at the hospital’s total patient population.
“The clinician is often looking at that one patient and saying, ‘Well, it could be MRSA,’ even if there is evidence to suggest that it is not,” says Avdic. “He or she doesn’t necessarily see the immediate harm to the patient because, again, antibiotics in some patients can be OK. I think it’s hard to see the harm until it really happens.
The Joint Commission mandate includes a new call for nursing to be involved in the stewardship team. “We’d like to expand our work in this institution to include nurses—not giving advice on antibiotic therapy—but helping to achieve safe antibiotic administration to patients,” says Cosgrove. “Nurses are giving the antibiotics, so they know if the patient is having a reaction. They know if the patient is really having diarrhea as a side effect. And they are able to prompt and ask questions.”