Experts Urge Hospitalists To Be Good Antimicrobial Stewards

It might seem basic, but ID experts say it’s too important not to repeat it over and over again: Hospitalists have to take care to narrowly tailor patients’ antibiotic treatments.

Starting a patient on broad-spectrum therapies might be necessary, but once the culprit is identified, the therapy should be honed, they say.

“I think frequently people who get started on antibiotics empirically in the emergency room, they’ll come into the hospital and they’ll kind of stay on them because folks are sometimes afraid to stop them,” Dr. Chansolme says. “But don’t be afraid to do that, particularly in this era of multi-drug resistance.”

Dr. Allen says scaling down treatment might not be easy in the middle of a busy day, but that it must be done.

“The path of least resistance is always to do nothing,” he says. “Even sometimes when you’re 100% certain [about the precise bug requiring

treatment], there’s this little voice in the back of your head going, ‘Yeah, but what if?’ It really does take some thought, and [courage], to stop antibiotics when the patient’s getting better on the current therapy.”

Dr. Gupta of the CDC says HM programs are in prime position to influence a hospital’s practices. “It’s important to remember appropriate use of antimicrobials and treatment and prevention of hospital-acquired infections when they are practicing that they’re often influencing physicians and training,” he says.

The experts raise a few red flags and offer tips that, if followed, should help hospitalists improve their antimicrobial stewardship:

Dr. Chansolme cautions that “not all fluoroquinolones are created equal” and are not interchangeable. In particular, he notes, moxifloxacin is not good for pseudomonas and doesn’t cover UTIs.

• Dr. Allen says that metronidazole does not have to be given if you’re already giving Zosyn or a carbapenem—it doesn’t add anything to the treatment.
• Dr. Allen also says it’s important to remember that cellulitis is almost always just a gram-positive infection, and does not require a very broad-spectrum antibiotic, a mistake he often sees.
• Dr. Orenstein says hospitalists should be on the lookout for the procalcitonin test, a laboratory study based on a prohormone that tends to be elevated in the setting of bacterial infections. The test can be used to possibly shorten the length of time a patient is given an antibiotic in certain cases.

“If elevated and you followed it, you could use it as a marker for when you could stop your antibiotics,” Dr. Orenstein said.

He says the test generally has been shown to allow doctors to shorten the course of antibiotics by one or two days, which can save on cost and length of stay.

“People need to be aware of it,” he says, “as I think a lot of places will be using it. It’s not quite ready for prime time.”

It might seem basic, but ID experts say it’s too important not to repeat it over and over again: Hospitalists have to take care to narrowly tailor patients’ antibiotic treatments.

Starting a patient on broad-spectrum therapies might be necessary, but once the culprit is identified, the therapy should be honed, they say.

“I think frequently people who get started on antibiotics empirically in the emergency room, they’ll come into the hospital and they’ll kind of stay on them because folks are sometimes afraid to stop them,” Dr. Chansolme says. “But don’t be afraid to do that, particularly in this era of multi-drug resistance.”

Dr. Allen says scaling down treatment might not be easy in the middle of a busy day, but that it must be done.

“The path of least resistance is always to do nothing,” he says. “Even sometimes when you’re 100% certain [about the precise bug requiring

treatment], there’s this little voice in the back of your head going, ‘Yeah, but what if?’ It really does take some thought, and [courage], to stop antibiotics when the patient’s getting better on the current therapy.”

Dr. Gupta of the CDC says HM programs are in prime position to influence a hospital’s practices. “It’s important to remember appropriate use of antimicrobials and treatment and prevention of hospital-acquired infections when they are practicing that they’re often influencing physicians and training,” he says.

The experts raise a few red flags and offer tips that, if followed, should help hospitalists improve their antimicrobial stewardship:

Dr. Chansolme cautions that “not all fluoroquinolones are created equal” and are not interchangeable. In particular, he notes, moxifloxacin is not good for pseudomonas and doesn’t cover UTIs.

• Dr. Allen says that metronidazole does not have to be given if you’re already giving Zosyn or a carbapenem—it doesn’t add anything to the treatment.
• Dr. Allen also says it’s important to remember that cellulitis is almost always just a gram-positive infection, and does not require a very broad-spectrum antibiotic, a mistake he often sees.
• Dr. Orenstein says hospitalists should be on the lookout for the procalcitonin test, a laboratory study based on a prohormone that tends to be elevated in the setting of bacterial infections. The test can be used to possibly shorten the length of time a patient is given an antibiotic in certain cases.

“If elevated and you followed it, you could use it as a marker for when you could stop your antibiotics,” Dr. Orenstein said.

He says the test generally has been shown to allow doctors to shorten the course of antibiotics by one or two days, which can save on cost and length of stay.

“People need to be aware of it,” he says, “as I think a lot of places will be using it. It’s not quite ready for prime time.”

It might seem basic, but ID experts say it’s too important not to repeat it over and over again: Hospitalists have to take care to narrowly tailor patients’ antibiotic treatments.

Starting a patient on broad-spectrum therapies might be necessary, but once the culprit is identified, the therapy should be honed, they say.

“I think frequently people who get started on antibiotics empirically in the emergency room, they’ll come into the hospital and they’ll kind of stay on them because folks are sometimes afraid to stop them,” Dr. Chansolme says. “But don’t be afraid to do that, particularly in this era of multi-drug resistance.”

Dr. Allen says scaling down treatment might not be easy in the middle of a busy day, but that it must be done.

“The path of least resistance is always to do nothing,” he says. “Even sometimes when you’re 100% certain [about the precise bug requiring

treatment], there’s this little voice in the back of your head going, ‘Yeah, but what if?’ It really does take some thought, and [courage], to stop antibiotics when the patient’s getting better on the current therapy.”

Dr. Gupta of the CDC says HM programs are in prime position to influence a hospital’s practices. “It’s important to remember appropriate use of antimicrobials and treatment and prevention of hospital-acquired infections when they are practicing that they’re often influencing physicians and training,” he says.

The experts raise a few red flags and offer tips that, if followed, should help hospitalists improve their antimicrobial stewardship:

Dr. Chansolme cautions that “not all fluoroquinolones are created equal” and are not interchangeable. In particular, he notes, moxifloxacin is not good for pseudomonas and doesn’t cover UTIs.

• Dr. Allen says that metronidazole does not have to be given if you’re already giving Zosyn or a carbapenem—it doesn’t add anything to the treatment.
• Dr. Allen also says it’s important to remember that cellulitis is almost always just a gram-positive infection, and does not require a very broad-spectrum antibiotic, a mistake he often sees.
• Dr. Orenstein says hospitalists should be on the lookout for the procalcitonin test, a laboratory study based on a prohormone that tends to be elevated in the setting of bacterial infections. The test can be used to possibly shorten the length of time a patient is given an antibiotic in certain cases.

“If elevated and you followed it, you could use it as a marker for when you could stop your antibiotics,” Dr. Orenstein said.

He says the test generally has been shown to allow doctors to shorten the course of antibiotics by one or two days, which can save on cost and length of stay.

“People need to be aware of it,” he says, “as I think a lot of places will be using it. It’s not quite ready for prime time.”