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SCORE trial: ASPs feasible, effective in small community hospitals
NEW ORLEANS — Antimicrobial stewardship programs that relied on infectious disease specialists significantly reduced antibiotic use in a handful of small community hospitals in the Western United States, according to the results of a cluster-randomized controlled trial.
Edward A. Stenehjem, MD, MSc, from the division of infectious diseases at Intermountain Medical Center in Utah, delivered the SHEA Featured Oral Abstract on the Stewardship in Community Hospitals — Optimizing Outcomes and Resources, or SCORE, trial.
In a recent study published in Clinical Infectious Diseases, Stenehjem and colleagues found that rates of antibiotic prescribing in small community hospitals were similar to those of larger hospitals. During his presentation at IDWeek 2016, Stenehjem noted that there are approximately 5,000 nonfederal hospitals in the U.S., and approximately 72% have fewer than 200 beds. Of those with 50 to 200 beds, 38.6% have antimicrobial stewardship programs (ASPs), and only 22.4% of hospitals with fewer than 50 beds have ASPs that meet all the CDC core elements of antibiotic stewardship.
New federal regulations are requiring ASPs in all U.S. hospitals, regardless of their size, by January 2017. However, there are few studies of ASPs in small community hospitals, Stenehjem said.
The SCORE trial included 15 small community hospitals in the Intermountain Healthcare system that were randomly assigned to one of three ASPs with increasing levels of ID support from a tertiary referral center.
“We set forth with our study to define an antibiotic stewardship strategy for smaller hospitals that optimizes outcomes while maximizing our resources,” Stenehjem said.
Program 1, used as a reference group, implemented basic ASP education and a 24/7 “infectious disease hotline,” staffed by ID specialists. These elements also were shared by the other programs, but Program 2 featured more advanced ASP education, a pharmacy-based prospective audit and feedback focused on broad-spectrum antibiotics, and it created restrictions on the use of antibiotics that were controlled by local pharmacy staff. Program 3, designed to mimic an academic-based ASP, had a prospective audit feedback program focused on a broader range of drugs, and its restrictions on the use of antibiotics were enforced by ID physicians and pharmacists. Further, ID specialists reviewed all multidrug-resistant cultures and positive blood cultures.
Stenehjem and colleagues calculated the change in antibiotic consumption — measured as adjusted rate ratios — during the 15-month intervention period.
Using a fixed effect model, compared with Program 1, Program 2 had no sizeable effect on the rate of total antibiotic use (RR = 0.96; 95% CI, 0.83-1.1), but it did lead to a 31% reduction in broad-spectrum antibiotic use (RR = 0.69; 95% CI, 0.53-0.91). Program 3, meanwhile, led to a 17% reduction in total antibiotic use (RR = 0.83; 95% CI, 0.72-0.94) and a 27% drop in broad-spectrum use (RR = 0.73; 95% CI, 0.56-0.95). The random effect model had similar point estimates but wider confidence intervals.
There were no differences in mortality or readmissions, Stenehjem said.
When looking at Clostridium difficile infections (CDI), the researchers noted a statistically significant decrease in health care-associated community-onset and hospital-onset cases in Program 2 (adjusted RR = 0.70; 95% CI, 0.49-0.99). Program 3 had a similar effect on CDI incidence (aRR = 0.68; 95% CI, 0.38-1.22) but did not reach statistical significance. The adjusted RR for Program 1 regarding CDI incidence was 1.27 (95% CI, 0.86-1.88). When compared with Program 1, only Program 2 led to a significant reduction in CDI cases (aRR = 0.55; 95% CI, 0.32-0.93). Program 3 had a similar point estimate but, again, did not reach statistical significance.
The infectious disease hotline was heavily used in Programs 2 and 3, Stenehjem said, with over 1,006 phone calls directed at adult ID providers alone.
“More stewardship support was associated with more infectious disease telephone support,” he said.
According to the researchers, the large variability in the size of the hospitals and the effect of the intervention between them was a limitation, and Stenehjem questioned whether the results were generalizable.
Nonetheless, he noted that higher-level ASPs in small community hospitals resulted in greater reductions in antibiotic consumption.
“Stewardship programs are not only feasible in small community hospitals, they can reduce antibiotic use if the appropriate resources are applied,” Stenehjem said. – by John Schoen
References:
Stenehjem E, et al. Abstract 1692. Presented at: IDWeek; Oct. 26-30, 2016; New Orleans.
Stenehjem E, et al. Clin Infect Dis. 2016;doi:10.1093/cid/ciw588.
Disclosure: The study was funded by the Joint Commission and Pfizer’s Independent Grants for Learning and Change. The researchers also report receiving investigator-initiated grants from Allergan.
Perspective
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The results of this study show that antibiotic stewardship programs in this setting can have a significant impact on decreasing antibiotic use; how such programs are structured and focused makes a difference in achieving the outcome of interest. More research is needed to understand the components of antibiotic stewardship programs that are most effective in small community hospitals. Many such hospitals do not have formal antibiotic stewardship programs — something that is expected to be mandated in the near future. If these programs are to have the desired impact on antibiotic use, and limited resources used effectively, we need to be creative and understand what works and what does not work in these settings. This study adds to that understanding.