Antimicrobial Stewardship

Reviewed and revised 20 December 2015

OVERVIEW

Antimicrobial Stewardship is defined as ‘an ongoing effort by a health-care institution to optimise antimicrobial use among hospital patients in order to improve patient outcomes, ensure cost-effective therapy and reduce adverse sequelae of antimicrobial use (including antimicrobial resistance)’

one of 5 key initiatives targeted by the Australian Commission on Safety and Quality in Health Care to combat Healthcare-associated infection (HAI)
together with infection control and infection surveillance, antimicrobial surveillance is one of the 3 key measures used to combat antibiotic resistance
needs to be appropriately resourced and part of the wider hospital quality improvement system

OBJECTIVES

aim to change antimicrobial prescribing to reduce unnecessary use and promote the use of agents less likely to select resistant bacteria

COMPONENTS

Involves a range of complementary strategies and interventions

Treatment guidelines with consideration of the demonstrated local incidence of antimicrobial-resistant pathogens
Multidisciplinary teams, involving infectious diseases physicians, clinical microbiologists, infection control practitioners and pharmacists
Includes policies for first line treatment of sepsis and empiric antimicrobial management of suspected infection
Formulary restrictions and approval systems for broad-spectrum and later generation antibiotics to ensure use is clinically justified
Plans for when to stop antibiotics based on organisms identified and nature of infection
Utilises prevalence data of microorganisms and assessment of their susceptibilities
Laboratory results available to guide antimicrobial therapy in a timely fashion
Monthly antimicrobial usage data available
Standard materials for training medical officers available
Mechanisms to audit and provide feedback to individual prescribers
Local expertise utilised to provide patient focussed ward rounds reviewing all positive microbiology and antimicrobial prescriptions
Computer-based prescribing systems
Dose optimisation and transition from IV to PO involving pharmacists

Core elements of hospital antibiotic stewardship programs (CDC)

Leadership commitment
- Dedicating necessary human, financial and IT resources
Accountability
- Appointing a single leader responsible for program outcomes
- Experience with successful programs show that a physician leader is effective
Drug expertise
- Appointing a single pharmacist leader responsible for working to improve antibiotic use
Action
- Implementing at least one recommended action, such as systematic evaluation of ongoing treatment need after a set period of initial treatment (ie “antibiotic time out” after 48 hrs)
Tracking
- Monitoring antibiotic prescribing and resistance patterns
Reporting
- Regular reporting information on antibiotic use and resistance to doctors, nurses and relevant staff
Education
- Educating clinicians about resistance and optimal prescribing

TIPS FOR IMPROVING ANTIBIOTIC USE

7 actions to improve antibiotic prescribing and use (from Antibiotic Awareness Week 2013: No action today, no cure tomorrow)

Obtain cultures before starting therapy
Use Therapeutic Guidelines: Antibiotic
Document indication and review date
Review and reassess antibiotics at 48 hours
Consider IV to oral switch
Seek advice for complex cases
Educate patients about antibiotic use

MINDME: The antimicrobial creed

M – Microbiology guides therapy
I – Indications should be evidence based
N – Narrowest spectrum required
D – Dosage appropriate to the site and type of infection
M – Minimise duration of therapy
E – Ensure monotherapy in most cases

STOPPING ANTIBIOTICS

In general, based on the therapeutic response and microbiology data, antibiotic therapy should be:

stopped in patients unlikely to have infections
undergo focusing and narrowing of treatment once the responsible pathogen is known
switched to monotherapy after day 3 whenever possible
discontinued after ~7 days for most patients

Longer duration of antibiotics is preferred in certain situations:

immunosuppressed
infections with multiresistant microorganisms
deteriorating course despite treatment
initial antibiotic regimen was inappropriate for the responsible pathogens

Drawbacks of prolonged antibiotic use include:

facilitates colonization with antibiotic-resistant bacteria
increased adverse effects

The role of biomarkers, such as procalcitonin, in determining when to stop antimicrobials is unclear

COMBINED ANTIBIOTICS

Multiple antibiotics may be prescribed simultaneously to:

ensure adequate empiric cover when infective organisms are unknown
treat multiple known infectious organisms with different antimicrobial sensitivities
for ‘synergistic effects’

Antibiotic synergy has only been shown to be of value in these settings

in vitro studies
patients with neutropenia
patients with bacteraemia
patients with >25% probability of death

Drawbacks of combined antibiotic use include:

no decrease in antibiotic resistance
increased adverse effects (e.g. nephrotoxicity)

EVIDENCE

Wagner B et al. Antimicrobial stewardship programs in inpatient hospital settings: a systematic review. Infect Control Hosp Epidemiol. 2014 Oct; 35 (10): 1209 – 28. Epub 2014 Aug 21. PMID: 25203174

Antimicrobial stewardship programs are associated with:

Improved concordance with guidelines
Improved prescribing patterns: decreased antimicrobial use or increased appropriate use
Improved microbial outcomes: including institutional resistance patterns or resistance in the study population
Assists in controlling outbreaks of multi-resistant organisms (where infection control does not)
Cost-neutral or better
Some evidence for reduced LOS

References and Links

Lifeinthefastlane.com

CCC — Procalcitonin

Journal articles

Doron S, Davidson LE. Antimicrobial stewardship. Mayo Clin Proc. 2011 Nov;86(11):1113-23. doi: 10.4065/mcp.2011.0358. PubMed PMID: 22033257; PubMed Central PMCID: PMC3203003.
Luyt CE, Bréchot N, Trouillet JL, Chastre J. Antibiotic stewardship in the intensive care unit. Critical care. 18(5):480. 2014. [pubmed] [free full text]
Wagner B et al. Antimicrobial stewardship programs in inpatient hospital settings: a systematic review. Infect Control Hosp Epidemiol. 2014 Oct; 35 (10): 1209 – 28. Epub 2014 Aug 21. PMID: 25203174

FOAM and web resources