Antibiotic Awareness in Veterans Affairs Hospitals – Insight from Dr. Mary Townsend

Briefly describe your work involving antimicrobial stewardship and antibiotic awareness.

I round daily with the ID consult service, conduct routine monitoring of positive cultures and leave stewardship notes when an intervention is needed, review and discuss restricted drug consults with the ID consult fellow, manage our outpatient parenteral antibiotic therapy (OPAT) list with the additional help of another pharmacist, attend ID clinic one half-day a week (this clinic is comprised of inpatient follow ups and HIV patients), and am the Co-Chair of the Antibiotic Stewardship Committee alongside Chris Hostler, MD. 

What stewardship initiative or antibiotic awareness effort are you most proud of that you have participated in or lead?

We have been very fortunate to have strong support from our hospital administration, ID attendings, pharmacy and P&T committees.  As a result, our Antibiotic Stewardship Committee has developed numerous policies on appropriate/judicious use of antibiotics.  Some examples include: business rules with a templated note which allow us to review all positive cultures in the hospital and leave recommendations, OPAT program policy, rapid diagnostic technology implementation, automatic infectious diseases consult for high risk infections (e.g., S. aureus bacteremia and fungemia), development of an UTI order set based on local antibiogram, C. difficile order set, fecal transplant protocol, and annual review of a surgical prophylaxis guideline.

One area that we have been wanting to expand antibiotic awareness is in our outpatient setting.  In 2017, we were lucky to be a part of a CDC Shepherd grant that allowed us to do this.  We are part of a VA multi-centered study evaluating acute respiratory tract infection (ARI) with an audit-feedback intervention and its impact on antibiotic prescribing rates and patient outcomes (Karl Madaras-Kelly, PharmD [Boise VA] is the project lead and Matt Samore, MD [Salt Lake City VA] is the PI). We have rolled this program out to our Emergency Department and three select primary care clinics.  

Have you measured the impact of this initiative; if so, what has the impact been?

Overall, we have had about a 15- 20% decline in antibiotic prescribing for ARIs.  In some of the primary care areas we have only recently rolled out the intervention, so we are hoping to get further reductions and then be able to sustain these results.

What actions do pharmacists take at your institution to optimize antibiotic use?

Since we are a teaching hospital affiliated with Duke, we have quite a few physicians and providers that rotate back and forth between institutions.  Our pharmacists are a phenomenal asset to help remind everyone of formulary restrictions and locations of order sets, monitor for IV to PO conversions, encourage the narrowing of antibiotics once cultures return with susceptibilities, and prompt teams to define durations of antibiotic therapy.  Our pharmacists are also great at reaching out to me if they have questions about antibiotic regimens or steering their teams to reach out to the ID consult service for help.

What is your primary goal for the next year to continue to improve antibiotic use?

We are looking to participate in another VA multi-centered quality-improvement initiative implementing a time-out policy for certain antibiotics in the inpatient setting.  Additionally, we are hoping to build additional order sets for our facility.

What is one pearl you have for non-ID trained pharmacists to help them be antibiotic stewards?

Less is sometimes more—critically evaluate your patients and work with your teams to identify appropriate durations of therapy. Long durations of antibiotic therapy can compromise the safety of patients and increase likelihood of future antibiotic-resistant infections.     

Mary Townsend, PharmD, AAHIVP

Co-chair, Antibiotic Stewardship Committee

Supervisor, Inpatient/Specialty Clinical Pharmacy Specialists

Durham VA Medical Center

Adjunct Professor, Campbell University College of Pharmacy & Health Sciences