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

• CCC — Procalcitonin

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

• Australian Commission on Safety and Quality in Healthcare — Antimicrobial Stewardship Resource Materials
• CDC: Core elements of hospital antibiotic stewardship programs. Available at URL:  http://www.cdc.gov/getsmart/healthcare/implementation/core-elements.html
• Safety and Quality: Antibiotic Awareness Week 2013