Preparing for the New and Revised Antibiotic Stewardship Requirements — Is Your Institution Ready?

Antibiotic stewardship is an important tool in the fight against the continuously growing problem of antibiotic resistance.

Starting January 1, 2023, all Joint Commission-accredited hospitals and critical access hospitals must meet the new and revised antibiotic stewardship requirements that were announced in June 2022. There are 12 elements of performance (EPs) that expand on the antibiotic stewardship expectations already in place. ¹

Does your institution have an antibiotic stewardship program? If not, now is the time to ensure you are ready for the new requirements.

Why Is Antibiotic Stewardship Important?

Antibiotic stewardship promotes programs, protocols, and best practices that improve the use of antibiotics. By using the right antibiotic at the right time at the right dose for the right duration, hospitals can improve patient safety and reduce antibiotic resistance.

Antibiotic Stewardship Improves Patient Outcomes

Antibiotic stewardship programs can help improve patient outcomes while reducing harms such as adverse events and increased antibiotic resistance.

Optimizing antibiotic selection, dosing, and duration can avoid antibiotic-related toxicity in patients. Up to 20 percent of hospitalized patients experience an adverse event while receiving antibiotics.⁵ Some of these adverse events can be serious and result in new or prolonged hospitalizations. Antibiotics like vancomycin and aminoglycosides can cause serious adverse events such as nephrotoxicity or ototoxicity. ^6,7

Additionally, people are 7 to 10 times more likely to develop a Clostridiodes difficile infection (CDI) while taking antibiotics and for up to one month afterward.⁸ CDI has become increasingly difficult to treat due to the development of resistance.

A systematic review of hospital antimicrobial stewardship programs found that when this program was in place patients had:

• decreased length of stay,
• fewer infection-related readmissions,
• and lower costs associated with their care.⁹

Antibiotic Stewardship Combats Antibiotic Resistance

Antibiotic resistance is one of the top ten global public health threats, according to the World Health Organization.¹⁰ Antibiotic stewardship can help to combat antibiotic resistance.

Antibiotic resistance is associated with worse patient outcomes, including excess mortality and morbidity, increased length of stay, and increased costs.¹¹

Initiation of antibiotic stewardship programs can decrease the total use of antibiotics resulting in a lower risk of healthcare-associated infections such as CDI, ventilator-associated pneumonia, and central line-associated bloodstream infections.¹²

What’s New in the Antibiotic Stewardship Requirements?

To agree with current scientific and professional organization recommendations, The Joint Commission (JCAHO) has revised its antibiotic stewardship requirements. Several requirements have been revised to clarify expectations, while others are completely new.¹ 

Allocating Financial Resources

Hospitals are expected to allocate financial resources to specifically support staffing and information technology for the antibiotic stewardship program.

Monitoring Antibiotic Use

Hospitals must monitor the use of antibiotics. They can do this by monitoring days of therapy per 1000 days present or 1000 patient days.

Alternatively, they can report antibiotic use data to the NHSN Antimicrobial Use Option of the Antimicrobial Use and Resistance Module.

Optimizing Antibiotic Prescribing

Hospitals must implement strategies to optimize antibiotic prescribing. They can use preauthorization or a prospective review, or both strategies.

A preauthorization strategy involves an internal approval process before specific antibiotics are used.

A prospective review process involves a member of the antibiotic stewardship committee reviewing and giving feedback about antibiotic prescribing patterns.

Implementing Evidence-Based Antibiotic Guidelines

The antibiotic stewardship program must implement at least two evidence-based antibiotic guidelines for common indications based on formulary options, local antibiotic resistance patterns, and the patient population.

A few examples of evidence-based guidelines to improve antibiotic use include:

• Area under the curve (AUC)-based dosing of vancomycin
• Community-acquired pneumonia
• Urinary tract infections
• Clostridioides difficile colitis
• Parenteral-to-oral antibiotic conversion
• Surgical prophylaxis
  

Evaluating Adherence

Hospitals must evaluate adherence to at least one of the evidence-based guidelines in use. Adherence can be measured either on a group level or at the individual prescriber level.

How to Prepare for the New Antibiotic Stewardship Requirements

All Joint Commission-accredited hospitals must have an antibiotic stewardship program that adheres to the requirements by January 1, 2023. Dosing software, like DoseMeRx, can simplify the preparation.

Plan the Budget

The new requirements specify that the hospital must allocate financial resources for both staff and information technology. Although it may seem difficult to allocate a portion of the hospital’s budget, studies have shown the cost-saving benefits of antimicrobial stewardship programs.⁹

DoseMeRx is another tool to help save money in the budget by reducing labor costs associated with individualized dosing. The integrated platform pulls patient data directly from the electronic health record (EHR) to generate dosing recommendations. This eliminates the need for your team to spend time hunting through the patient chart for data.

Bayesian dosing of vancomycin available with DoseMeRx can decrease costs by streamlining lab draws and dosing times. Additionally, it can reduce the risk of adverse events such as acute kidney injury (AKI), which can increase the length of stay.¹³ Patients with AKI can generate excess costs due to new or prolonged hospitalizations and additional laboratory testing and imaging.⁵

With DoseMeRx, dosing software solutions start as low as $1,990 and can range up to about $10,000 for larger sites.

Assemble an Antibiotic Stewardship Committee

A physician and/or pharmacist should be appointed to lead the antibiotic stewardship committee. The leader will be responsible for developing the program, quality assessment, and hospital staff education.

The antibiotic stewardship program leader doesn’t have to do this alone. The embedded analytics platform available in DoseMeRx makes it easy to monitor progress and workflow using powerful visualization tools and real-time usage statistics.

DoseMeRx offers Bayesian dosing continuing education courses, live training sessions, and support from the clinical advisory board to make staff education easier.

Develop Evidence-Based Guidelines

Hospitals must implement at least two evidence-based antibiotic guidelines. The DoseMeRx platform includes infectious disease PK/PD models are clinically validated and reviewed by the clinical advisory board.

The vancomycin dosing available from DoseMeRx complies with the recent vancomycin dosing guidelines recommending a switch from trough-based dosing to AUC-based dosing.¹⁴ If your institution is not already using AUC dosing for vancomycin, the time to start is now.

In addition to better patient outcomes, switching to AUC-based dosing for vancomycin saves time and money by allowing for streamlined lab draws and dosing and decreasing the risk of adverse events.

DoseMeRx has several infectious disease drug models currently available, including:

• Amikacin
• Gentamicin
• Meropenem
• Linezolid
• Piperacillin
• Tobramycin
• Vancomycin
• Vancomycin (obese)
• Vancomycin (hemodialysis)
• Vancomycin (pediatric)
• Vancomycin (neonate)
• Voriconazole IV
• Voriconazole Oral
  

Set up Data Collection

The antibiotic stewardship program must collect, analyze, and report data to both hospital leadership and physicians.

The analytics embedded in DoseMeRx provides a wealth of real-time data with very little effort using the clinical analytics dashboard, including:

• Time to therapeutic target
• Patient risk indicators (including risk of AKI)
• Trough vs. AUC outcomes
• Average daily dose amounts
  

Using these analytics, it is easy to monitor appropriate antibiotic use and dosing with measurable outcomes.

Identify Areas of Opportunity

To comply with antibiotic stewardship requirements, hospitals should take action to identify opportunities for improvement.

DoseMeRx provides interactive visualizations of data, making it easy to gain insights into clinical outcomes. With dynamic date ranges, quickly and easily discover whether goals are being met with data as recent as the day prior.

Evaluate adherence to evidence-based antibiotic guidelines with DoseMeRx’s usage statistics. It’s possible to see the team’s dosing practices, including usage trends, drug model usage, and dosing reports by user.

Conclusion

It often feels that we are expected to do more with less in the hospital. It can be daunting to find room in the budget for new requirements.

Meeting the new antibiotic stewardship requirements from The Joint Commission (JCAHO) doesn’t have to be so difficult. The solutions from DoseMeRx provide a cost-efficient and time-saving way to successfully implement the new requirements.

References:

1. The Joint Commission. (2022, June 20). New and revised requirements for antibiotic stewardship. https://www.jointcommission.org/-/media/tjc/documents/standards/r3-reports/r3_antibioticstewardship_july2022_final.pdf
2. Centers for Disease Control and Prevention. (2021, April 28). Core elements of hospital antibiotic stewardship programs. https://www.cdc.gov/antibiotic-use/core-elements/hospital.html
3. Centers for Disease Control and Prevention. Inpatient antibiotic use. Retrieved November 4, 2022. https://arpsp.cdc.gov/profile/inpatient-antibiotic-use/all?hidden=
4. Cusini A, Rampini SK, Bansal V, et al. Different patterns of inappropriate antimicrobial use in surgical and medical units at a tertiary care hospital in Switzerland: a prevalence survey. PLoS One. 2010 Nov 16;5(11):e14011. doi: 10.1371/
5. Tamma PD, Avdic E, Li DX, Dzintars K, Cosgrove SE. Association of adverse events with antibiotic use in hospitalized patients. JAMA Intern Med. 2017 Sep 1;177(9):1308-1315. doi: 10.1001
6. Patel S, Preuss CV, Bernice F. Vancomycin. StatPearls [Internet]. Last update September 2022.
7. Block M, Blanchard DL. Aminoglycosides. StatPearls [Internet]. Last update July 2022.
8. Centers for Disease Control and Prevention. (2022, June 27). Your risk of C. diff. https://www.cdc.gov/cdiff/risk.html
9. Nathwani D, Varghese D, Stephens J, Ansari W, Martin S, Charbonneau C. Value of hospital antimicrobial stewardship programs [ASPs]: A systematic review. Antimicrob Resist Infect Control. 2019 Feb 12;8:35. doi: 10.1186
10. World Health Organization. (2021, November 17). Antimicrobial resistance. https://www.who.int/news-room/fact-sheets/detail/antimicrobial-resistance
11. de Kraker ME, Davey PG, Grundmann H; BURDEN study group. Mortality and hospital stay associated with resistant Staphylococcus aureus and Escherichia coli bacteremia: Estimating the burden of antibiotic resistance in Europe. PLoS Med. 2011 Oct;8(10):e1001104. doi: 10.1371
12. Al-Omari A, Al Mutair A, Alhumaid S, et al. The impact of antimicrobial stewardship program implementation at four tertiary private hospitals: results of a five-years pre-post analysis. Antimicrob Resist Infect Control. 2020 Jun 29;9(1):95. doi: 10.1186
13. Abdelmessih E, Patel N, Vekaria J, et al. Vancomycin area under the curve versus trough only guided dosing and the risk of acute kidney injury: Systematic review and meta-analysis. Pharmacotherapy. 2022 Sep;42(9):741-753. doi: 10.1002
14. Rybak MJ, Le J, Lodise TP, et al. Therapeutic monitoring of vancomycin for serious methicillin-resistant Staphylococcus aureus infections: A revised consensus guideline and review by the American Society of Health-System Pharmacists, the Infectious Diseases Society of America, the Pediatric Infectious Diseases Society, and the Society of Infectious Diseases Pharmacists. Am J Health Syst Pharm. 2020 May 19;77(11):835-864. doi: 10.1093