Home' The Source : First Quarter 2018 Contents SOURCEBOOK UNDER THE MICROSCOPE
In July 2016, the Food and Drug Administration (FDA) issued a
safety alert on the serious side effects associated with quinolones,
a class of antibiotics that includes ciprofloxacin and levofloxacin.
These drugs are convenient in many ways, notably because they
treat a broad range of infections and are effective both intravenously
and orally. But they have a debilitating and permanent impact on
tendons, muscles, joints, nerves and the central nervous system.
The drug class is also associated with a higher risk for Clostridium
difficile (C. diff ) and the emergence of antibiotic resistance in
Staphylococcus aureus and other bacteria.
With a robust antimicrobial stewardship program already in place,
Jersey City Medical Center, a member of RWJBarnabas Health, was
able to respond immediately, launching an awareness campaign
that included clinician education materials, a lecture series and,
the campaign’s pièce de résistance, “Save the Quinolones” pins
worn on the lab coats of antimicrobial stewardship team members.
“I underestimated how much wearing a pin around the hospital
would get people’s attention,” says Steven Smoke, PharmD, BCPS,
clinical pharmacist and co-chair of Jersey City Medical Center’s
antimicrobial stewardship program. “The pins were very effective
as conversation starters, which was precisely the goal. We wanted
clinicians to know that quinolones should be reserved for cases
where alternative treatment options don’t exist.”
At the start of the campaign, quinolones were the most-used
class of antibiotics at Jersey City Medical Center. The results are
still preliminary, but Smoke estimates the campaign has helped cut
usage of quinolones by half and made a small dent in the
number of methicillin-resistant Staphylococcus aureus
(MRSA) cases. This year, Smoke’s team is launching a
similar awareness campaign, dubbed “Why PPI?” for
proton pump inhibitors, usage of which has been linked
to diarrhea associated with C. diff.
A Regulatory Requirement
Clinician education like the kind being carried out by
Smoke’s team at Jersey City Medical Center is one of
seven required elements in the Joint Commission’s anti-
microbial stewardship standard, which went into effect
in January 2017. The standard, which largely mirrors
national guidelines created by the Centers for Disease
Control and Prevention, also requires hospitals to elevate
antimicrobial stewardship as an organizational priority,
assign a multidisciplinary team to oversee the program,
develop and utilize various protocols to aid in antimi-
crobial stewardship, and collect, analyze and report data on the
effectiveness of the program.
Jason Braithwaite, PharmD, MS, BCPS, senior director of clinical
pharmacy services for HealthTrust, says meeting these require-
ments is proving difficult for some hospitals, especially smaller ones.
Challenges include finding physician leaders who have an interest
in antimicrobial stewardship and educating frontline clinicians,
who may not be hospital employees.
By and large, the most common challenge facing antimicro-
bial stewardship programs is tracking metrics beyond the basics.
Guidelines from the Infectious Diseases Society of America rec-
ommend hospitals track defined daily dose per 1,000 patient days.
But the Joint Commission is pushing hospitals to start incorpo-
rating more outcomes-based metrics, such as rates of C. diff, adverse
events, morbidity and mortality. The problem for hospitals lies in
both IT limitations and the inability to decisively attribute a clinical
outcome to antimicrobial stewardship.
“Facilities have some good ideas about what outcomes would be
important to track, but the ability to track them is more difficult
than they thought,” Braithwaite says.
Jersey City Medical Center’s Smoke is keeping track of both anti-
biotic use and C. diff rates as part of its antimicrobial stewardship
program. Over a one-year period, antibiotic use dropped 8 percent;
however, the decrease in C. diff rates was not statistically significant.
And, the question remained: Was the 8 percent drop in antibiotic use
due to the antimicrobial stewardship program or something else?
“Any kind of outcome has so many variables that drawing defini-
tive conclusions will always be hard, especially in a hospital setting
where a randomized controlled trial simply isn’t feasible,” Smoke
says. “We’re forced to rely on before-and-after studies. They can’t
tell us something with certainty, but they’re the best tool we have
to demonstrate what happened.”
Smoke says it’s important to take the time to conduct before-and-
after research with every antimicrobial stewardship initiative. “It’s
Continued on page 10
8 The Source | First Quarter 2018
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