In making progress towards preserving antibiotics for future generations it is of tremendous importance to get the message out about antimicrobial stewardship. It is a topic that spans the spectrum of healthcare professions and extends from hospitals into the community.
Authored By: Timothy Gauthier, Pharm.D., BCPS AQ ID
In 2015 I wrote an article for Pharmacy Times. This is an update of that article.
Antimicrobial stewardship programs are being deployed across the spectrum of the healthcare landscape in an effort to combat the spread of antibiotic-resistant pathogens and preserve our antimicrobial drugs.
Upon searching for the term “steward” online, you will find a definition that states “the person who takes care of the castle while the lord is away.” When it comes to antimicrobial drugs (i.e., antibiotics, antifungals, antivirals) we are all responsible to take care of them on behalf of society as a whole.
Guidelines published by leading professional societies identify the primary goal of antimicrobial stewardship is to: “…optimize clinical outcomes while minimizing unintended consequences of antimicrobial use, including toxicity, the selection of pathogenic organisms (such as Clostridium difficile), and the emergence of resistance” . A secondary goal is to: “…reduce health care costs while maintaining the highest possible quality of care.” The fact of the matter is that when the primary goal is achieved, the effect is that the secondary goal is also frequently achieved. So, while antimicrobial stewardship is not about reducing costs, good stewardship leads to reduction of healthcare costs.
Considering the broad goals and the vast number of activities which may be undertaken in the name of antimicrobial stewardship, it may serve useful to simplify it. One way to do this is by placing things into two categories: (1) what is being done and (2) what can be done. This is where antimicrobial stewardship programs step in.
Antimicrobial stewardship programs aim to achieve the aforementioned goals by working to optimize existing practices while selecting, implementing, and providing oversight on new activities and interventions.
Now that you are familiar with what antimicrobial stewardship is, here are five things worth knowing about it…
1. Antimicrobial stewardship is here to stay.
We are now in an era during which there are times when the drugs in our conventional antimicrobial armamentarium have no clinical utility against infection-causing bacteria . With little assistance in sight from the antimicrobial drug development pipeline, antimicrobial stewardship combined with infection prevention are the weapons we now have for conserving the miracle of antibiotics .
Today, substantial commitments are being made to implement and expand antimicrobial stewardship initiatives and powerful healthcare organizations are backing the antimicrobial stewardship movement. One example of this that is getting a great deal of attention comes form The Joint Commission, which accredits over 21,000 healthcare organizations and programs in the United States. The Joint Commission now has a standard on antimicrobial stewardship that is active and applies to both hospitals and nursing care centers . A similar requirement is expected from the Center for Medicare and Medicaid Services in the near future.
2. Antimicrobial stewardship is a team sport with the patient at the center.
A pharmacist and physician with advanced training in infectious diseases are identified as ideal champions of an antimicrobial stewardship program. They collaborate with providers, nurses, pharmacists, administrators, information technologists, laboratory personnel, and other health care professionals to improve existing systems and support the safe and appropriate use of antimicrobial agents.
An inter-professional team is necessary to confront the complex challenges antimicrobial stewardship programs face.
When it comes to antimicrobial stewardship it’s teamwork that makes the dream work. And when the dream works, the patient wins.
3. Antimicrobial stewardship is not synonymous with infectious diseases.
Antimicrobial stewardship efforts aim to promote the safe and appropriate use of drugs used for preventing or treating infectious diseases, but the implementation of these initiatives oftentimes includes a great deal of non-direct patient care work. For example, it is common for a stewardship program to perform a practice analysis, which is followed by an intervention coupled with education to staff, then a follow-up analysis and eventually continuous quality assurance monitoring.
What this means is that the field of antimicrobial stewardship includes considerations from the world of clinical infectious diseases, but also includes elements of operations, education, quality, administration, information technology, and more. For this reason many people that go into infectious diseases do not enjoy antimicrobial stewardship, as it is not where their true passion lies, even though that may be where most jobs are these days.
4. Everyone is an antimicrobial steward.
Hear someone say “antimicrobial steward” and you are likely to think of health care professionals such as physicians, pharmacists and nurses. It does not stop there though. We are all stewards of antibiotics.
Your role in promoting awareness and discouraging inappropriate antimicrobial use extends outside the health care facility. So, when you hear that an aunt who gave your cousin some expired levofloxacin from 12 years ago for a “snort, sniffle, and sneeze” most likely representing a viral upper respiratory infection for which antibiotics will not provide benefit , please do not ignore it; speak up and say something.
Health care professionals in particular have a responsibility to educate others that antimicrobials can be toxic, should not be taken without proper supervision, and are a precious resource. It may be helpful to direct patients to reliable online sources for more information, such as the those provided by the United States Centers for Disease Control and Prevention website.
5. We still have a lot to learn about antimicrobial stewardship.
The amount of literature in the field of antimicrobial stewardship has expanded in recent years , but few of the recommendations in current guidelines are rated “strong” or based upon a high level of evidence [1,7]. Further muddying the waters, each institution has its own unique combination of resources and opportunities to address, so a one-size-fits all approach is unfortunately not a valid option.
There is a substantial need for robust studies assessing a variety of issues within different practice settings. Some areas with the most significant need of further study include pediatric, long-term care, and outpatient populations .
1. Dellit TH et al. 2006 Infectious Diseases Society of America and Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clinical Infectious Diseases. 2007; 44:159-177.
2. Antibiotic resistance threats in the United States, 2013. US Department of Health and Human Services, Centers for Disease Control and Prevention. Available at: http://www.cdc.gov/drugresistance/pdf/ar-threats-2013-508.pdf. Accessed 31 January 2017.
3. Boucher HW et al. 10 x 20’ progress – development of new drugs active against gram-negative bacilli: an update from the infectious diseases society of America. Clinical Infectious Diseases. 2013; 56(12):1685-94.
5. Snort Sniffle Sneeze: no antibiotics please. Centers for Disease Control and Prevention TV. Available at: http://www.cdc.gov/cdctv/diseaseandconditions/lifestyle/no-antibiotics-please.html. Accessed 31 January 2017.
6. Santibanez M, Veulens MV, Jenistova T, Aragon L, Gauthier TP. Characteristics of primary literature in the field of antimicrobial stewardship, 2000-2013. Infection Control and Hospital Epidemiology. 2015; 36(5):616-18.
7. Barlam TF, et al. Implementing an Antibiotic Stewardship Program: Guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. Clinical Infectious Diseases. 2016; 62(10): e51-e77.