Current State of Antimicrobial Stewardship at Solid Organ and Hematopoietic Cell Transplant Centers in the United States

Abstract

Objective To assess the extent of antimicrobial stewardship programs (ASPs) at solid organ (SOT) and hematopoietic cell transplant (HCT) centers in the United States (US). Design An 18-item voluntary survey was developed by Memorial Sloan Kettering Cancer Center and University of Miami to gauge current antimicrobial stewardship practices in transplant patients, examine the availability and perceived usefulness of novel diagnostics and azole levels to guide therapy, and identify challenges for implementation of ASPs at these centers. Participants The survey was distributed electronically to Infectious Disease physicians and pharmacists at adult and pediatric SOT and HCT centers during May 1–22, 2015. Facilities were de-identified. Results After duplicate removal, 71 (56%) of 127 unique transplant centers in 32 states were analyzed. Forty-four sites (62%) performed ≥ 100 SOT annually, and forty (56%) performed ≥100 HCT annually. Top five stewardship activities encompassing transplant patients included formulary restriction, guideline development, prospective audit & feedback, education, and dose optimization. Respiratory viral panels (100%), azole levels (97%), and serum/BAL galactomannan (88%) were perceived as most useful to guide therapy. Apparent challenges to antimicrobial stewardship included: undefined duration for certain infections (90%), diagnostic uncertainty (80%), the perception that antibiotic-resistant infections required escalation (71%), prescriber opposition (69%), and costly drugs (63%). Conclusions ASP activities were performed at many adult and pediatric SOT and HCT centers in the US. Diagnostic and therapeutic uncertainty in transplant patients are challenging for ASPs. Collaborative research to examine the impact of antimicrobial stewardship practices in SOT and HCT should be explored.

Antifungal stewardship considerations for adults and pediatrics

“…1 A recent US survey of adult and pediatric transplant centers found that monitoring is not done robustly in HCT or SOT patients despite the presence of an ASP with the exception of Clostridium difficile rates, followed by antimicrobial costs. 107 Because prescribing of antifungal agents is disproportionately high for transplant (and other highly immunocompromised) patients, efforts to examine whether antifungal stewardship interventions are effective in these patients should be encouraged. While standards have not been established regarding the frequency of monitoring, it seems reasonable to monitor an ASP's clinical impact at least annually with more frequent assessments depending on programmatic needs.…”

Impact of an antimicrobial stewardship program in the antimicrobial-resistant and prevalence of clostridium difficile infection and amount of antimicrobial consumed in cancer patients

“…(4). Over the past few decades, published literature related to safety and efficacy of antibiotic stewardship strategies in high-risk immunocompromised hosts such as SOT recipients and those with hematologic malignancies exposed to cytotoxic chemotherapy and prolonged neutropenia is limited (8).…”

“…There has been a dramatic reduction in the development of antimicrobial agents with novel mechanisms of action to combat the rising spread of infections caused MDR organisms, although implementation challenges in immunocompromised hosts have been described (4,8). In general, antimicrobial-stewardship programs (ASPs) can help to improve clinical outcomes, limit antibiotic resistance and reduce medical costs by limiting the inappropriate use of antimicrobials in hospitals (1,3,10).…”

“…It is unknown whether antimicrobial stewardship efforts are enclosing only the general patient population or whether immunocompromised hosts such as cancer and SOT are being included (7,8).…”

“…Duration of antimicrobial therapy and difficulty with source control is not clearly defined in many infections for immunocompromised hosts which may lead clinicians to prescribe broader and longer courses of antimicrobials than they would with a normal host (5,8).…”