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

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

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

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.