By Don Sadler
Antimicrobial agents are critical to destroying or severely inhibiting the growth of pathogenic microorganisms. Since antibiotics are given preoperatively in hospital operating rooms and ambulatory surgery centers as part of SSI prevention, it’s critical for hospitals and ASCs to create an antimicrobial stewardship program (ASP).
What is Antimicrobial Stewardship?
The Association for Professionals in Infection Control and Epidemiology (APIC) defines an ASP as follows:
“Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multi-drug resistant organisms.”
According to APIC, the term antimicrobial encompasses the treatment options for all forms of microbes. These include antibiotics to treat bacteria, antifungals to treat fungi and antivirals to treat viruses.
“Antimicrobial stewardship provides guidance for the safe and cost-effective use of antimicrobial agents,” says Linda K. Connelly, PhD, MSH, ARNP, CNOR, COL (retired) USA Nurse Corps and a professor at the University of North Florida Brooks College of Health School of Nursing.
“A primary goal of this stewardship is to minimize unintended consequences such as toxicity and resistance to the antimicrobial that will optimize clinical outcomes,” Connelly adds.
“A coordinated ASP is imperative to promoting the proper use of antimicrobials,” says Vangie Dennis, MSN, RN, CNOR, CMLOS, executive director, WellStar AMC. “It should include improvement in patient outcomes, along with assists in sustaining a reduction in microbial resistance and the spread of infections that can be caused by multidrug-resistant organisms.”
According to Terri Link, MPH, BSN, CNOR, CIC, CAIP, FAPIC, product manager, guideline implementation tools with the Association of periOperative Registered Nurses (AORN), antimicrobial
stewardship in the OR and ASCs includes the appropriate timing and the right dosage and redosing for extended procedures.
“Antimicrobials should be administered before the incision is made or before the tourniquet is inflated, and dosages should be administered based on the patient’s weight,” says Link. “Proper documentation will allow for audits of appropriate use of antibiotics, including surveillance for SSIs.”
Another consideration is the use of antibiotics in the case of allergies. “Appropriate screening and consultation with a pharmacist may ensure that the second line antibiotic is appropriate and effective,” says Link.
Workflow should also be a consideration. “Some antibiotics take longer to infuse and decisions about what antibiotic to use are based on this,” says Link. “Having an interdisciplinary team that develops standardized processes for antibiotics is important in any antimicrobial stewardship program.”
Link emphasizes that an ASC’s governing body – which is interdisciplinary and includes either a pharmacist on staff or contracted pharmacist – should establish practices that include the appropriate antibiotics for the procedure being performed and the organisms most likely to be the cause of an SSI for that procedure.
“This is often a broad-spectrum antibiotic that covers a wide range of organisms,” says Link.
The Role of the Perioperative Team
Connelly stresses the importance of the perioperative team working together to make sure that the antimicrobial stewardship program is in place and followed for each patient. “Perioperative nurses need to be included on the team that manages antimicrobials,” says Connelly.
“In fact, I believe that the perioperative nurse can be the lynchpin for this process,” Connelly adds. “Perioperative nurses work closely with surgeons and have their ear, which is important since surgeons are at the top of the list of doctors who engage in prescribing antibiotics.”
“Not only do surgeons oversee antibiotic prescriptions for surgical prophylaxis on a daily basis, but they also usually manage surgical infections,” says Connelly.
In her role as faculty, Connelly says she includes the topic of antimicrobial stewardship in her perioperative and medsurg courses. “I teach students that nurses are integral to organizational change,” she says. “Nurses need to take a leadership role in the guidance of optimal use of therapies and stay current on evidence-based practices and guidelines.”
AORN is an excellent source to stay current on evidence-based practices in the perioperative setting, Connelly adds. “But nurses should go beyond AORN to other sources such as the CDC as well,” she says.
Connelly believes that the perioperative nurse’s role can start with enhancing infection prevention and control. “This is especially true in an ambulatory setting since these patients will be assessing themselves after their short stay at the facility,” she says. “This makes nurse education key.”
According to Dennis, antimicrobial stewardship needs to be applied across the continuum of care. “This is especially true within an ASC setting, since there are limitations with patient relationships and it can be difficult to reconnect with patients after discharge,” she says. “Being proactive helps decrease infection rates while improving patient care and outcomes.”
Avoiding Antibiotic Overuse
Beverly Kirchner, BSN, RN, CNOR, CASC, corporate compliance officer with SurgeryDirect LLC, notes that studies have shown that overuse of antibiotics is resulting in multi-drug resistant organisms and antibiotic-resistant infections.
She points to data compiled by the CDC revealing that at least 30 percent of antibiotic courses prescribed in the outpatient setting are unnecessary. Total inappropriate antibiotic courses may approach 50 percent of all outpatient antibiotic use, notes the CDC.
“Our goal is to wipe out SSIs, not create a bigger problem by providing antibiotics that are not needed or are not appropriate for the patient,” says Kirchner. “At the very least, antimicrobial stewardship programs should address a commitment to decrease the use of antibiotics and encourage physicians to write fewer antibiotic prescriptions for patients after surgery.”
Connelly concurs, noting that antibiotic resistance is a “global threat” and that the overuse of antibiotics contributes to the problem, along with patients not completing their prescriptions. “Perioperative nurses can educate patients about the importance of completing prescriptions and even follow up with them after they’ve been discharged,” she says.
Kirchner encourages facility leaders and infection preventionists to work together to write policies and procedures addressing antibiotic usage and then follow them. “The leadership team needs to be educated in the appropriate use of antibiotics and ensure that all team members are educated as well,” she says.
“Tracking and reporting of SSIs is a critical component of a stewardship program,” Kirchner adds. “The infection preventionist, working with the pharmacy consultant, needs to track antibiotic use and report not only this, but also if the use of the antibiotics was appropriate for the patient based on the diagnosis.”
Kirchner suggests that facilities can reduce SSIs and the overuse of antibiotics by following best practices in a number of different areas, such as using safe injection practices, using clippers to remove hair before procedures in the perioperative area and practicing effective hand hygiene.
“In addition, perioperative nurses should encourage patients to cleanse their skin prior to admission by educating them on the importance of this during the preadmission call,” she adds. “Nurses should also provide extensive post-operative instructions to the patient’s family regarding infection prevention practices, such as the importance of frequent hand washing.”
Perioperative Nurse’s Role is Critical
Connelly believes that the role of perioperative nurses in antimicrobial stewardship cannot be overstated.
“Perioperative nurses are very involved in antimicrobial therapy,” she says. “Therefore, I feel they should also be very involved in antimicrobial stewardship.”