Antimicrobial Stewardship

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.

Seven Core Elements

Leadership Commitment

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:

  • Formal statements, signed by chief administrator(s), that the facility supports efforts to improve and monitor antibiotic use. sample
  • Include stewardship-related duties in job descriptions and annual performance reviews. samples
  • Assure that key staff from relevant departments are given sufficient time to contribute to stewardship activities.
  • Support and encourage staff training and education on antibiotic stewardship.
  • Encourage staff from all related areas to support stewardship activities.

Accountability

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:

  • Clinicians and department heads: As prescribers of antibiotics, it is vital that clinicians are fully engaged in and supportive of efforts to improve antibiotic use
  • Infection preventionists: Coordinate facility-wide monitoring and prevention of healthcare-associated infections and can assist in auditing, analyzing, and reporting of data. Preventionists can also assist in monitoring and reporting resistance trends and educating staff on the importance of stewardship efforts.
  • Quality-improvement staff: Work to assure that optimal antibiotic use meets medical quality and patient safety standards.
  • Laboratorians: Provide recommendations and guidance on the most appropriate lab tests to use and how results will be delivered and communicated. Laboratory staff can also help to create and interpret the facility’s antibiogram. An antibiogram is a facility’s cumulative antibiotic resistance report.
  • IT staff: Integrate stewardship protocols into existing workflow and implement clinical decision support for antibiotic use at point of care, create prompts for clinicians to review antibiotic use, and facilitate the collection and reporting of data
  • Nurses:

Drug expertise

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:

  • Automatic alerts to identify potential duplications in medications
  • Time-sensitive, automatic stop orders for certain antibiotic prescriptions, especially antibiotics used for surgical prophylaxis
  • Alerts to prevent antibiotic-related drug-drug interactions
  • Encouraging prescribers to document dose, duration, and indication
  • Development and implementation of facility-specific treatment recommendations.

Action

Whether a facility is starting an antimicrobial stewardship program or is expanding an existing program, it is important to:

  • Implement policies that support optimal antibiotic use.
  • Use specific interventions from one of three categories: broad interventions, pharmacy-driven interventions, and infection and syndromic-specific interventions.
  • Avoid implementing too many policies or interventions at the same time.
  • Prioritize interventions based on facility’s unique needs, overall antibiotic use, and tracking and reporting metrics.

Overall, a facility should first implement policies that apply in every situation. Two examples include:

  • Document dose, duration, and indication for antibiotic.
  • Use facility-specific treatment recommendations.

Broad Interventions

  • Antibiotic time outs
  • Prior authorization
  • Prospective audit and feedback

Pharmacy-Driven Interventions

  • Automatic changes from intravenous to oral antibiotic therapy
  • Dose adjustments
  • Dose optimization
  • Automatic alerts in situations when antibiotics might be unnecessary or duplicative
  • Time-sensitive automatic stop orders
  • Detection and prevention of antibiotic-related drug-drug interactions

Infection and Syndromic-Specific Interventions

  • Community-acquired pneumonia
  • Urinary tract infections (UTIs)
  • Skin and soft tissue infections
  • Empiric coverage of methicillin-resistant Staphylococcus aureus (MRSA) infections
  • Clostridium difficile infections
  • Treatment of culture-proven invasive infections

Track antibiotic use and outcomes.

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.

Process measures

  • Periodic assessments of the use of antibiotics or the treatment of infections to determine the quality of antibiotic use.
  • Assess if antibiotics are being given in a timely manner.
  • Assess prescribers’ compliance with the facility’s antibiotic-use policies.

Outcome measures

  • Track rates of hospital-onset Clostridium difficile infections.
  • Track antibiotic resistance.
  • Monitor antibiotic resistance at the patient level.
  • Monitor antibiotic costs.

Reporting

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.

Education

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.