Antimicrobial Stewardship

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 focused 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. 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

LITFL

Journal articles

  • Doron S, Davidson LE. Antimicrobial stewardship. Mayo Clin Proc. 2011 Nov;86(11):1113-23. PMC3203003.
  • Luyt CE, Bréchot N, Trouillet JL, Chastre J. Antibiotic stewardship in the intensive care unit. Critical care. 18(5):480. 2014. [pubmed]
  • Wagner B et al. Antimicrobial stewardship programs in inpatient hospital settings: a systematic review. Infect Control Hosp Epidemiol. 2014 Oct; 35 (10): 1209 – 28. PMID: 25203174

FOAM and web resources


CCC 700 6

Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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