Antimicrobial Stewardship Implementation
In its broader holistic sense, antibiotic stewardship is the careful and responsible management of antibiotic resources in the interest of long-term sustainability.
There is general consensus that antibiotic resistance development and spread can be curtailed by limiting antibiotic use, discouraging misuse, and reducing the burden of infectious disease.1 An optimally functioning antimicrobial stewardship program is instrumental in accomplishing these goals. It can have significant positive impacts on morbidity and mortality, (Fig. 1) and potentially reduce healthcare costs in the range of 20-35%.2,3 Importantly, it plays a critical role in broad-based, larger scale efforts to help preserve our antibiotic resources for future generations.
Fig. 1 Decreased mortality through appropriate antimicrobial therapy
Source: adapted from Kollef, M. et al. (1999) Inadequate antimicrobial treatment of infections: a risk factor for hospital mortality among critically ill patients. Chest 115:462-74 (cited by the CDC, 12 Steps to Prevent Antimicrobial Resistance: Hospitalized Adults) [Presentation]4
Champions of Stewardship Programs
Numerous countries have championed national stewardship programs—with diverse strategies and varying degrees of success. Belgium's experiments in mass media campaigns resulted in a 36% decline in antibiotic prescriptions. This prompted France to initiate its own successful Antibiotics are not Automatic Anymore campaign, which is directed at the public and general practitioners, particularly in the implementation of rapid strep diagnostic tests for upper respiratory infections.
Other programs, e.g., Sweden's effective STRAMA initiative, the newly evolving Vietnam Resistance Program (VINARES), South Africa's Best care… Always! and the EU's ABS International, focus primarily on hospital-based stewardship efforts. In contrast, the Get Smart: Know When Antibiotics Work campaign in the U.S. is an example of an ongoing, multi-faceted approach that targets the general public, as well as healthcare facilities.5-10
Building an Antimicrobial Stewardship Strategy
While grass roots activists work to bring legislation that will reduce antibiotic use in food animals11,12 and thereby lower antibiotic contamination of the environment, it is imperative that hospitals, community healthcare workers and the public access the knowledge for rational use of antibiotics, and more importantly, initiate and consistently implement interventions and practices that will reduce the unnecessary use of antibiotics, now estimated at >50%.13
Ideally, hospitals should develop and maintain a comprehensive antimicrobial stewardship program (ASP) that encompasses the full chain of caregivers. This would include the pharmacist, laboratory technologist, attending physician, nurses, housekeeping, and infection control teams. In addition to regular communication, strategies that facilitate the activities of this team can include formulary restriction by the pharmacy; education; guidelines and clinical algorithms; antimicrobial order forms; and computerized decision support (Fig. 2).
Fig. 2 Antimicrobial stewardship strategies for impacting the stages of patient treatment
Source: adapted from MacDougall, C. (2006) Antibiotic Stewardship Programs: proven strategies to preserve medicine's "magic bullets". APUA Newsletter 24(1):1-3.14
The Role of Rapid Diagnostics
The 'test' element of the Test Target Treat paradigm is a critical link in the physician's response to an infected patient and one that is sometimes overlooked in stewardship discussions and models. Rapid diagnostics for distinguishing between viral and bacterial infections greatly facilitate the decision of whether or not to prescribe antibiotics. Recent advances in this field have brought much-needed products to aid physicians in the arenas of bedside, clinic and field diagnosis, but much more can be done to rapidly match disease agents with appropriate therapies. Cost and limited access still present major roadblocks to much of the developing world.
Fig. 3 Impacts of rapid diagnostic testing in optimizing antimicrobial selection
Source: adapted from Goff, DA et al. (2012) Using rapid diagnostic tests to optimize antimicrobial selection in antimicrobial stewardship programs. Pharmacother 32(8): 677-687.15
- Lesprit, P. and Brun-Buisson, C. (2008) Hospital Antibiotic Stewardship. Curr Opin Infect Dis:21:344-9.
- Nowak, M.A. et al. (2012) Clinical and economic outcomes of a prospective antimicrobial stewardship program. Am J Health-Syst Pharm 69:1500-1508.
- Carling, P. et al. (2003) Favorable impact of a multidisciplinary antibiotic management program conducted during 7 years. Infect Cont Hosp Epidemiol: 24:699-706.
- Kollef, M. et al. (1999) Inadequate antimicrobial treatment of infections: a risk factor for hospital mortality among critically ill patients. Chest 115:462-74 (As Cited by CDC 12 Steps to Prevent Antimicrobial Resistance: Hospitalized Adults) [Presentation])
- Edgar, T et al. (2009) Sustainability for behavior in the fight against antibiotic resistance: a social marketing framework. J Antimicrob Chemother 63: 230-237.
- Huttner, B. et al. (2009) “Antibiotics are not automatic anymore”—the French national campaign to cut antibiotic overuse. PLoS Med; 6(6).
- Allerberger, F. et al. (2008) Optimization of antibiotic use in hospitals – antimicrobial stewardship and the EU project “ABS International”. Chemother. 54: 260-67.
- Wertheim, H.F.L. et al. (2013) Providing impetus, tools and guidance to strengthen national capacity for antimicrobial stewardship in Vietnam. PLoS Med, 10(5).
- Best Care…Always! (BCA) Homepage. Date accessed: 05/02/2014 http://www.bestcare.org.za/
- Centers for Disease Control and Prevention (CDC). Get Smart: Know When Antibiotics Work. Date accessed: 06/21/2013 http://www.cdc.gov/getsmart/
- Shah, H. et al. (2012) GAINing ground on resistance. APUA Newsletter 30: 3 2012.
- Outterson, K. (2012) All Pain no Gain- Need for Prudent Antimicrobial Use Provisions to Complement the GAIN Act. APUA Newsletter 30:1 2012.
- World Health Organization (WHO) (2010) Medicines: rational use of medicines. Fact sheet No. 338. Date accessed: 06/21/2013 http://www. wiredhealthresources.net/resources/NA/WHO-FS_MedicinesRationalUse.pdf
- MacDougall, C. (2006) Antibiotic Stewardship Programs: proven strategies to preserve medicine’s “magic bullets”. APUA Newsletter 24(1):1-3.
- Goff, D.A. et al. (2012) Using rapid diagnostic tests to optimize antimicrobial selection in antimicrobial stewardship programs. Pharmacother 32(8): 677-687.