Belinda Ostrowsky, MD
Antimicrobial Stewardship Team
Priya Nori, MD
Julie Williamson, PharmD
Longer-than-needed durations, medical regimens with redundant coverage, delayed regimens, suboptimal dosing, and use of drugs that don’t target the causal pathogen are examples of inappropriate antimicrobial therapy, which has been linked to issues such as higher antibiotic resistance rate, longer duration of hospitalization, increased costs, and adverse events ranging from mild skin eruptions to increased mortality. Recent studies have suggested that a significant percentage of antibiotics prescribed in healthcare settings are inappropriate.
The emergence and spread of resistance is particularly pressing given the stagnation of new antimicrobials on the market. Reduced pharmaceutical sponsorship, increased regulatory requirements, and an overall failure to deliver novel antibiotic agents have created low return on investment for antibiotic development.
In July 2008, Montefiore Medical Center initiated a multifaceted interdisciplinary program to educate, support, and advise practicing physicians throughout its extensive Bronx network of hospitals, ambulatory care clinics, and nursing homes. The program, which recently extended services to the Children's Hospital at Montefiore (CHAM) and Montefiore Wakefield Campus, seeks to foster judicious antimicrobial use toward better patient care and safety; improved clinical outcomes; reduced resistance; and fewer healthcare-acquired infections such as C. difficile colitis, a potentially fatal complication that can develop from the use of commonly prescribed antibiotics.
Montefiore's antimicrobial stewardship program focuses on inpatient units to formulate a system-wide approach to consistent treatment protocols. This plan is based on guidelines from the Infectious Diseases Society of America (IDSA), aggregate data on antimicrobial resistance and microbiology at Montefiore, and exemplary clinical methods practiced by departments throughout the system. Requiring providers to justify use of broad-spectrum antibiotics, optimizing dosages and transitioning administration methods (primarily intravenous to oral), and identifying opportunities to routinely de-escalate and streamline treatment regimens are key components of the stewardship protocol. A new care algorithm, changes to the Emergency Department's medication management system, and revised antibiotic prescribing rules have improved antibiotic selection for community-acquired pneumonia.
Dr. Ostrowsky was clinical principal investigator of "Toolkit for Reduction of Clostridium difficile Infections Through Antimicrobial Stewardships", a project to help hospitals implement antimicrobial stewardship programs directly targeting C. difficile. The toolkit, sponsored by the Association for Healthcare Quality Research and Control (AHRQ), helps individual hospitals identify antibiotics linked to C. difficile, develop strategies to improve appropriate antibiotic use, and sustain effective antimicrobial stewardship.
The Antibiotic Stewardship Program has resulted in a significant decrease in the utilization of restricted antimicrobials, despite an increasing inpatient census, rising costs of medications, and antibiotic shortages.
Big Bugs, Few Drugs: Infectious Disease and Antimicrobial Stewardship
AHRQ toolkit helps hospitals improve antibiotic selection to reduce deadly C. difficile infections (AHRQ)
Toolkit for Reduction of Clostridium difficile Infections through Antimicrobial Stewardship
Belinda Ostrowsky, MD
The Evaluation and Research on Antimicrobial Stewardship's Effect on Clostridium difficile (ERASE C. difficile) Project
The ever-increasing public health problem of Clostridium difficile infection (C. difficile), particularly among people over age 65, is often associated with inappropriate prescribing of antibiotics. Initiated in 2008 and led by Dr. Belinda Ostrowsky, Montefiore's multifaceted interdisciplinary Antimicrobial Stewardship Program educates, supports, and advises practicing physicians to foster judicious antimicrobial use toward decreased C. difficile infection throughout Montefiore's Bronx healthcare network.
Dr. Ostrowsky and colleagues are now leading a multi-site collaborative program working with local facilities, hospital associations and national public health agencies to reduce the instance of C.difficile by creating, implementing and studying stewardship activities targeted at this infection. The initiative, sponsored by the U.S. Department of Health & Human Services' Agency for Healthcare Research and Quality, has resulted in the development of a toolkit to aid other facilities in implementing stewardship activities and identifying the most effective methods to impact prescribing and related outcomes such as CDI at their respective facilities.
Antimicrobial Stewardship Toolkit (AHRQ)
Research Highlights: Infectious Disease (Montefiore Medical Center)