When looking at facility-level antibiotic use, we tend to focus on the costs of the drugs themselves. While drug cost alone can be substantial, antimicrobial stewardship produces big financial benefits largely because it prevents expensive “ripple effects” of unnecessary antibiotic use. More than half of all hospitalized patients receive antibiotics, and it’s estimated that a third of these prescriptions are inappropriate. This overprescribing can result in unnecessary annual spending in excess of $900,000 per facility.
Let’s take a look at the factors driving this exorbitant cost of antibiotic overuse:
Most antibiotics given in healthcare facilities are administered in IV form. This requires a laundry list of equipment purchases to maintain, including IV catheters, IV tubing, medication bags, syringes, IV pumps, sterile dressings, sterile gloves, sterile drapes and central line insertion kits. The popular peripherally-inserted central catheter (PICC line) typically costs $1500 or more per patient.
Placing and maintaining venous access, programming and troubleshooting pumps, hanging and documenting individual doses of IV medication – it all requires substantial nursing time. Then there’s the additional hours of pharmacy time for mixing and delivering doses of IV antibiotics, followed by therapeutic monitoring for a number of these medications. Don’t forget the cost of IV teams to maintain those difficult lines and phlebotomists to draw the monitoring labs.
Besides the cost of the antibiotics themselves, IV antibiotic therapy requires heparin flushes, saline flushes and pricey thrombolytics like alteplase for when central lines clot off. If a patient has an adverse reaction to one of those unnecessary antibiotics, you can also throw in the cost of drugs like antihistamines, steroids, antiemetics, anti-diarrheals, antipyretics and maybe even epinephrine for severe reactions.
Clostridioides difficile infection (yes, it’s no longer Clostridium) can be provoked by any antibiotic use – even narrow spectrum – and patients remain at risk for C diff infection for up to three months after any antibiotic exposure. In addition to the relatively high costs of oral vancomycin and fidaxomicin, C diff comes with its own set of ripple effects on cost – gowns, gloves, bleach-based cleaning products, additional EVS time, additional waste disposal costs and delayed transitions in care, among others.
Increased antibiotic resistance
We all know that, the more you use antibiotics, the less likely they are to be effective down the road. This is especially true in long-term care facilities, where patients can become colonized with increasingly resistant organisms from receiving multiple broad-spectrum antibiotic courses over time or from coming into contact with other patients who already have highly-resistant organisms. As antibiotic resistance increases, so does the cost of the drugs and equipment required to treat the resistant organisms.
Adverse patient events
Central lines carry the risk of line-associated DVT, as well as central-line associated bloodstream infection (CLABSI) – both of which can substantially increase cost of care and length of stay. Even administration via peripheral IV poses risks of infiltration and septic thrombophlebitis. Many common IV antibiotics can lead to kidney failure, and this outcome, along with other severe adverse drug reactions, can increase transfers to acute care facilities. More medication prescribing creates more opportunities for serious medication errors. Then there’s the consistent observation that patients with multidrug-resistant organisms (MDROs) just don’t do as well, with longer lengths of stay, higher overall costs of care and higher mortality.
Worse quality metrics
We touched on a lot of these measures above, but it’s worth noting that many of them carry their own financial penalties in addition to the cost of the events themselves. These may be direct penalties from a regulatory body like CMS or indirect penalties from decreased admissions and referrals when unfavorable publicly-reported quality measures scare away patients. Metrics that can be adversely affected by antibiotic overuse include MDRO rates (including C difficile), CLABSI rates, average length of stay, total cost of care, readmission rates and patient mortality.
What can you do about antibiotic overuse in your facility?
Inappropriate antibiotic prescribing is often driven by fear – fear that we might be missing something in the realm of infection when a patient looks particularly ill. Maybe you think the patient has a viral pneumonia, but it’s tempting to cover for bacterial pneumonia “just in case.” If that patient has spent significant time in a healthcare facility, it’s also tempting to cover for any and all resistant organisms they might have acquired during their stay. Healthcare providers want their patients to do well, so this tendency to “play it safe” is understandable. However, playing it safe by blasting patients with broad-spectrum antibiotics frequently leads to increased costs and worse outcomes downstream.
Antimicrobial stewardship programs (ASPs) are multidisciplinary team efforts within a healthcare facility focused on promoting proper prescribing of antimicrobials (including antibiotics) by providing feedback to prescribers. They aim to reduce excessive antimicrobial use, both in terms of length of therapy and in limiting the use of unnecessarily broad-spectrum agents. The CDC, CMS and the Joint Commission all promote implementation of ASPs – in fact, CMS requires most participating facilities to have some form of ASP. Ideally, these programs should include an Infectious Disease (ID) physician, given the complexity of decision-making involved with antibiotic prescribing. The Joint Commission actually states in their standard for ASPs that an ID physician should be involved, whenever available.
We have a significant shortage of ID physicians in the US, and available specialists tend to cluster around large, urban hospitals, leaving thousands of healthcare facilities without ID coverage. Fortunately, the recent rise of telemedicine has expanded access to this critical specialty. Both the Joint Commission and the Infectious Diseases Society of America (IDSA) support the use of telemedicine to direct an ASP, so this can be a great option for facilities without local access to an ID physician.
Improper antibiotic use greatly increases healthcare costs and worsens patient outcomes, but these effects can be mitigated with input from clinicians with expertise in the use of antimicrobials. ASPs save facilities money, improve quality metrics and, most importantly, lead to better treatment results for patients. Is it time to add or expand antimicrobial stewardship services at your facility?