Antimicrobial stewardship is any activity that helps promote the appropriate dose, type, and duration of antibiotics. The discovery and use of antibiotics has transformed the practice of medicine. Infections that were once fatal became treatable, and medical procedures like chemotherapy and organ transplants became possible.
The quick initiation of antibiotics to treat infections has been proven to save lives; however, 20%-50% of all antibiotics prescribed in U.S. acute-care hospitals are either unnecessary or inappropriate. Antibiotics can have serious side effects, including adverse drug reactions and Clostridium difficile infection. Unnecessarily prescribed antibiotics place patients at-risk for serious adverse events and provide patients with no clinical benefit. The misuse of antibiotics has also contributed to an increase in antibiotic resistance, which has become one of the most serious threats in public health. The Centers for Disease Control and Prevention estimates more than two million people are infected with antibiotic-resistant organisms, resulting in approximately 23,000 deaths annually.
Antimicrobial stewardship is based on the "three Ds", the right drug, the right dose and the right duration.
Leadership support is critical to the success of any initiative, including antibiotic stewardship programs. It is necessary to assure the allocation of staff, financial, and information technology resources. Staff and management who are directly or indirectly involved need to know that administration supports and encourages the success of the initiative.
Some examples of leadership support are:
One of the first steps in starting an antibiotic stewardship program is identifying a lead or co-leads. Formal training in infectious diseases and/or antibiotic stewardship is helpful for program leaders. That is why physicians and pharmacists are often chosen to spearhead these efforts.
Larger facilities and acute-care hospitals have been able to hire full-time staff to develop and/or manage stewardship programs, while smaller programs may rely on existing staff’s expertise or contracting with off-site professionals.
Stewardship teams can benefit from the support and involvement of the following groups of clinical professionals:
A pharmacist, especially one who has experience or training in improving antibiotic use, is a critical member of a healthcare facility’s team. Facilities who do not have a pharmacist on site should consider partnering with other healthcare facilities in the community for access to that expertise. Pharmacy-focused interventions can include dose adjustments and dose optimization. In addition, pharmacists can assist with:
Whether a facility is starting an antimicrobial stewardship program or is expanding an existing program, it is important to:
Overall, a facility should first implement policies that apply in every situation. Two examples include:
Tracking the prescribing of antibiotics in the facility is important because it will help stewardship team members identify areas for improvement and to assess the impact of any improvement efforts that are implemented. Both processes and outcomes can be tracked and measured.
Tracking antibiotic use and outcomes is only beneficial if the information is reported back to the prescribers themselves, the facility's antimicrobial stewardship team, and the facility's executive leadership. By sharing this information, prescribers and staff can identify where improvements can be made or where interventions should be targeted. Reporting of both antibiotic use and antibiotic resistance in a facility can help clinicians make more informed decisions in patient care and potentially prevent misuse of antibiotics.
In addition to providing information to prescribers and staff, reporting facility-level data on a regional or national scale will show how a facility compares to national or state baselines.
Acute care facilities report to the National Healthcare Safety Network (NHSN) about Clostridium difficile (C-diff) and other resistant-bacterial healthcare-acquired infections. NHSN has also developed an Antibiotic Use and Resistance module for acute-care facilities to assist in reporting of antibiotic use and resistance data. The module was designed to help facilitate risk-adjusted benchmarking of antimicrobial usage and monitor trends of antibiotic usage across facilities at a regional and national level.
Any antibiotic stewardship program should provider regular updates and/or training on antibiotic prescribing, antibiotic resistance, and infectious disease management on updated or emerging local or national trends.