Antimicrobial Stewardship

Clinical Strengths

RUMC and CCH Stroger Hospital boast longstanding and effective antimicrobial stewardship programs (ASPs), whose precepts are fully integrated into ID practice and training. RUMC’s ASP has been designated an IDSA Centers of Excellence in 2018. Led by Dr. Won, the program has 2 full time adult ID pharmacists, 1 pediatric ID pharmacist, 1 pediatric ID physician, and the program is assisted by 6 rotating hospital pharmacy residents and several ICU/Emergency room pharmacists. Stroger’s ASP, with 2 ID pharmacists and led by Dr. Schwartz since 1994, has innovated in numerous domains, consulting regularly with the Illinois Department of Public Health and collaborating in research with the CDC.

Both hospitals perform regular surveillance and intervention for problem-prone antimicrobial use based on data derived from patients’ electronic health records; Rush uses the Epic antimicrobial stewardship module to review patients receiving restricted antimicrobials, identify drug/bug mismatches, and find opportunities for de-escalation and dosing optimization (e.g., beta-lactam allergy policy and order-set implementation decreased aztreonam use by 93%). Newly positive blood cultures and associated patient management are prospectively reviewed at both hospitals, and both regularly report electronic antimicrobial use measures. Both hospitals offer detailed infection management guidelines and have successfully targeted and decreased use of broad spectrum and/or costly drugs in a variety of settings.

Fellows receive didactics in antimicrobial use and stewardship as part of their core training. They participate in stewardship interventions during their inpatient clinical service by reviewing the records of and intervening when needed for patients with newly positive blood cultures, by fielding off-hour requests for restricted antimicrobials, and by learning, modeling and teaching on core ASP concepts in their everyday clinical interactions with non-ID colleagues. In addition, interested fellows are welcome to participate in regular ASP meetings and in ASP-related quality improvement and research projects, as described below.

Research Excellence

Our ASPs provide ample opportunities for interested fellows to participate in mentored clinical research, including an option for a third year of dedicated research training. Recent stewardship-related research projects include:

  • An ethnographic approach to interrogating antimicrobial stewardship
  • Analysis of enteric gram negative bacilli susceptibilities to inform empiric antimicrobial recommendations
  • Impact of antimicrobial stewardship intervention with and without rapid pathogen identification for bloodstream infections
  • Prediction of infection by carbapenem-only susceptible organisms in hospitalized patients
  • Impact of procalcitonin-based and conventional antimicrobial stewardship on antimicrobial use and resistance in the Rush and Stroger Hospital MICUs
  • Stewardship collaboration with the microbiology laboratory in the era of rapid diagnostic techniques
  • Clinical epidemiology of hospital anti-pseudomonal beta-lactam use: guideline concordance by indication and clinical findings

Recent stewardship projects of ID fellow:

  • 2017: Enrique Cornejo Cisneros, Masters of Clinical Research Thesis, Impact of Antimicrobial Stewardship Intervention for blood stream infections with and without rapid pathogen identification on antimicrobial use and patient outcomes

Recent stewardship abstracts by recent pharmacy residents, internal medicine residents, and ID fellows:

  • 2017: Vu B, Varughese C, Wang S, Hanson A, Geswein L, Gurnani P, Ackerbauer A, Harpe S, Won S. Prevalence and Predictors of Infections Due to Carbapenem-Only Susceptible Organisms After Escalation of Antibiotic Therapy in Hospitalized Patients. Poster session (66892) presented at: 2017 ID Week; 2017 Oct 4-8; San Diego, CA.
  • 2016: Cornejo-Cisneros E, Morency-potvin P, Wang S, Simms A, Nguyen D, Hanson A, Singh K, Trenholme GM, Won S. Impact of a newly implemented antimicrobial stewardship program for patients with bloodstream infections (BSI) in the absence of rapid diagnostic technology (RDT). Poster session presented at: 2017 ID Week; 2017 Oct 4-8; San Diego, CA.
  • 2016: Pirasteh A, Wang S, Hanson A, Peksa G, Won S, Segreti J, Harrison H, Lee J. Antimicrobial Stewardship initiative to reduce antibiotic use in asymptomatic bacteriuria. Poster session presented at: 2017 ID Week; 2017 Oct 4-8; San Diego, CA.
  • 2016: Pirasteh A, Hanson A, Peksa G, Segreti J, Won S, Wang S. “Antimicrobial Stewardship Initiative to Reduce Antibiotic Use for Asymptomatic Bacteriuria” Poster Presentation. MAD-ID antimicrobial stewardship conference, May 2016.

Recent stewardship abstracts and publications through Stroger Hospital:

  • Morency-Potvin P, Schwartz DN, Weinstein RA. Antimicrobial Stewardship: how the microbiology laboratory can right the ship. Clin Microbiol Rev 2016;30:381-407.
  • Schwartz DN. Antimicrobial stewardship in US hospitals: is the cup half-full yet? Clin Infect Dis 2016;63:450-452.
  • Schwartz DN, McConeghy KW, lyles RD, Wu U, Glowacki RC, Itokazu GS, Kieszkowski P, Xiang Y, Hota B, Weinstein RA. Computer-assisted antimicrobial recommendations for optimal therapy: analysis of prescribing errors in an antimicrobial stewardship trial. Infect Control Hosp Epidemiol 2017; 38(7):854-859 (Epub June 2, 2017).
  • Peglow SR, Itokazu G, Williams B, Schwartz DN and the Illinois Collaborative for Healthcare Antimicrobial Stewardship Enhancement (ICHASE). Integrating Retrospective Antimicrobial (AM) Use Audit with Physician (MD) Education and Prospective Post-Prescriptive Review with MD Feedback: Proof of Concept with Focus on Diabetic Foot Infections (DFIs). Poster presentation at IDWeek 2014, October 8-12, Philadelphia PA, abstract 208.
  • Morency-Potvin P, Itokazu GS, Glowacki RC, Schwartz DN. Optimizing unrestricted anti-pseudomonal beta-lactam (APBL) antibiotic use: appropriate indication selection is necessary but not sufficient. European Congress of Clinical Microbiology and Infectious Diseases, Amsterdam, the Netherlands, April 9 – 12, 2016; abstract EV0671.
  • Schwartz DN, Alu C, Morency-Potvin P, Itokazu G. Catalyst for antimicrobial stewardship improvement (CASI): a pilot implementation guidance program for Illinois acute care hospitals. Poster presentation at the Society for Healthcare Epidemiology of America, St. Louis, MO, March 29-31, 2017, abstract 355.

Other Opportunities

We are fully committed to giving our fellows a robust training in stewardship. Not only will he/she be able to participate in daily stewardship rounds and making calls and recommendations to physicians, but he/she can participate or lead any number of ongoing stewardship projects, eg. Indications for all antimicrobials, 48 hour time out, lead multi-disciplinary and multi-specialty development of guidelines/order sets, evaluation of antimicrobials to be added to formulary and/or to the restricted list, learn to generate and interpret stewardship metrics, and give educational talks to house staff and different service lines. As RUMC is part of a network of Rush Health, he/she will also be able to help develop system-wide guidelines. Other opportunities include participating in weekly stewardship meetings, quarterly anti-infective subcommittee meetings, bimonthly PNT (Pharmacy, Nutrition, and Therapeutics) committee meetings, and quarterly presentations to hospital quality leadership. Regarding formal education, he/she will be enrolled in the IDSA’s Core Antimicrobial Stewardship curriculum, which we are piloting from July 2018.