Q&A with
Keith Teelucksingh, PharmD

Pharmacy Purchasing & Products: What are the data requirements to drive a successful antimicrobial stewardship program?
Keith Teelucksingh: Some contemporary metrics proposed by groups such as the CDC and The Society for Healthcare Epidemiology of America (SHEA) require the ability to search electronic health records (EHRs) and obtain information, such as administration of antimicrobials (date, time, and amount), in addition to the location of the patient in the hospital when they received these medications. There are resources available to ensure accurate record keeping and searching capacity for this data, but selection is largely dependent on the EHR software a facility is using and the skill set of their information technology (IT) personnel in extracting information from it. 

Having access to data is vital to accurately measuring, evaluating, and reporting outcomes. Many different outcomes have been cited in the literature, ranging from decreased antimicrobial usage to reduction in bacterial resistance patterns. Some facilities use metrics such as length of stay as an outcome measurement for their programs. Determining which metrics to use depends largely on what information is drawn out of the database, as there is no set standard. While the ideal gauge is a simple metric that measures specific, appropriate antimicrobial usage, unfortunately there does not appear to be a single solution at this time. 

PP&P: What resources are available to determine the appropriate metrics for evaluating antimicrobial usage? 
Teelucksingh: The Infectious Diseases Society of America (IDSA), as well as SHEA, has published guidelines on using metrics to evaluate outcomes of antimicrobials.¹ In addition, an article was published in May that discusses defining quality metrics for antimicrobial stewardship programs. Five specific metrics were proposed: 

• Days of therapy per 1000 patient-days
• Number of patients with organisms that are drug-resistant
• Mortality associated with antimicrobial-resistant organisms
• Conservable days of therapy among patients with community-acquired pneumonia (CAP), skin and soft-tissue infections (SSTI), or sepsis and bloodstream infections (BSI) 
• Hospital readmissions within 30 days of discharge in which the diagnosis was CAP, SSTI, sepsis, or BSI²

At the present time, however, because no standardization of these measuring tools has been developed, it remains the responsibility of individual facilities to determine what data to track. There is a national trend toward using the days of therapy metric to evaluate overall antimicrobial usage.

Furthermore, the types of interventions that are made, such as IV to PO conversions, de-escalation of therapy, and discontinuation of unnecessary antibiotics, are all important to review. Kaiser Permanente medical centers in northern California track drug usage data, as well as any interventions that are being performed on antimicrobial therapy.

Another approach is to track microbiological data, such as the rates of resistance of certain problematic bacteria, such as Pseudomonas aeruginosa, which tend to be harder to treat. From there, a facility may choose to limit their use of antibiotics that spur resistance in that organism. Beginning with microbiological outcomes is often the best place to start, and from there, you can branch out to evaluate what other quality metrics to track.

PP&P: Are there challenges inherent to managing data in an antimicrobial stewardship program?
Teelucksingh: When approaching an antimicrobial stewardship program, the fundamental question that must be answered is: What data does the antimicrobial stewardship team need to track? Because a robust antimicrobial stewardship program requires multidisciplinary support and must encompass so many practice elements, it may be challenging to gain consensus on what information is to be tracked. The most basic iteration requires cohesive coordination among pharmacy, the microbiology laboratory, and the chemistry laboratory; in addition, this information ideally should all be captured in the EHR. At this time, unfortunately, few EHR systems have been designed with the capacity to provide complex feedback on antimicrobial stewardship. However, most EHR systems do have the ability to capture multiple data points, as well as the capacity to generate an eMAR that includes admission dates. The overwhelming challenge is the ability to generate timely reports from the EHR. Therefore, the imperative is to maintain a robust and proactive IT department that can extract those data points from the EHR. In the future, significant utility will be gained if the functionality to provide sophisticated reports detailing antimicrobial data is built in to EHR development. 

PP&P: How can CPOE be an effective instrument in antimicrobial stewardship programs?
Teelucksingh: CPOE can serve as a powerful tool to improve antimicrobial stewardship by providing support to clinicians in the earliest stages of patient care. Logic can be built into order templates for various disease states that ensures the right drug, dose, and duration are presented to the clinician at the point of order entry. Consensus guidelines have been published for many of these infectious disease states, and CPOE can help improve adherence to them. The range of application is wide, and potentially quite significant, as guidance can be applied to many common scenarios—from CAP to peri-operative antibiotics used for surgical prophylaxis. 

In the most advanced versions of CPOE, microbiology and patient-specific parameters (eg, allergies and laboratory results) also can be integrated at the point of order entry, enabling clinicians to make the most appropriate decisions upfront. For example, a sophisticated form of CPOE would take a disease state, such as CAP, and incorporate the antibiotics and other medications as recommended by consensus guidelines for that indication into the order template. The next step is incorporating patient-specific data, such as renal function, allergies, patient interactions, etc, to identify the most appropriate medications and filter out any medications that are inappropriate for the patient based on those parameters. The result of this process is that only the most streamlined antibiotic choices for that patient, including microbiological data, are presented to the ordering clinician. 

It is important to note that although these capabilities would be ideal, few—if any—CPOE systems currently in use have this capacity. The required programming to achieve this high level of function is extremely complex. Incorporating the patient-specific data as well as the microbiologic data remains challenging for most, if not all, facilities. Consequently, collaboration between IT and clinical personnel to best optimize CPOE development is mandatory. 

PP&P: What does the IT specialist bring to the antimicrobial management team?
Teelucksingh: The IT expert has a crucial role to play in antimicrobial stewardship programs, especially in the age of the EHR. He or she must function as a computer-savvy liaison who interfaces with individuals from various disciplines: pharmacy, infectious disease physicians, infection control preventionists, microbiologists, and possibly quality control specialists. These individuals have diverse perspectives on antimicrobial stewardship and each will require a different way to view data. The responsibility of the IT specialist is to access and disseminate these data to all stakeholders in a timely manner. 

As EHR systems continue to mature, the role of the IT professional will synchronously grow and transform. As such, an enhanced knowledge of medical terminology will likely benefit IT professionals. Access to high-level data allows providers to make accurate patient care judgments and ultimately streamline and improve the quality of care, leading to improved outcomes.

References

1. Dellit TH, et al. Clin Infect Dis. 2007;44:159-177.
2. Morris AM, et al. Infect Control Hosp Epidemiol. 2012;33(5):500-506.

Keith Teelucksingh, PharmD, is an infectious disease pharmacist practicing at the Kaiser Permanente Oakland Medical Center and a volunteer facilty member at the UCSF School of Pharmacy. Keith graduated from the University of Florida College of Pharmacy and completed a pharmacy practice residency and a specialty residency in infectious disease at UCSF. 

Disclaimer: The views expressed in this article are the author’s alone, and do not necessarily reflect those of Kaiser Permanente.