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
- Australian Commission on Safety and Quality in Healthcare — Antimicrobial Stewardship Resource Materials
- CDC: Core elements of hospital antibiotic stewardship programs. Available at URL: http://www.cdc.gov/getsmart/healthcare/implementation/core-elements.html
- Safety and Quality: Antibiotic Awareness Week 2013
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