Publication of data that contributes to the body of knowledge in antimicrobial stewardship is essential to progressing this important field. Here, a respected researcher and editor provides insight into publishing and the future of antimicrobial stewardship.
Interview By: Timothy Gauthier, Pharm.D., BCPS-AQ ID
The spread of drug-resistant pathogens is a threat to human health worldwide . In attempting to combat this growing threat, antimicrobial stewardship activities are identified as a method for ensuring the safe and appropriate use of existing antimicrobial agents.
Recently, in April 2016, the Infectious Diseases Society of America (IDSA) in conjunction with the Society for Healthcare Epidemiology of America (SHEA) released a second guideline on the topic of antimicrobial stewardship . The focus of this guideline is on implementing an antimicrobial stewardship program. Unfortunately, many of the statements presented in this document are weak recommendations based upon low-quality evidence.
Although there have been more publications in the area of antimicrobial stewardship in recent years , additional work is required to provide data which can substantiate stronger practice recommendations.
To facilitate discussion on the topic of publishing and antimicrobial stewardship, the following is provided. Here, Dr. Preeti Malani answers 5 questions I posed to her, which provide insight and context into the current state of publishing and antimicrobial stewardship. Dr. Malani is a professor of medicine at the University of Michigan and current associate editor at The Journal of The American Medical Association (JAMA). She is also one of the authors on the new IDSA/SHEA antimicrobial stewardship guideline.
1. What comes to mind when you hear the term “antimicrobial stewardship”?
I remember first hearing the term “antimicrobial stewardship” around 2003. Before the word stewardship became integrated into medical parlance, we tended to think and talk more about “antimicrobial restriction”, even “antibiotic policing” and less about “stewardship”.
For me, the term stewardship implies careful and thoughtful use of antimicrobials with input from other clinicians. Stewardship focuses on the idea of optimizing use—picking the best agent or combination of agents for a particular patient or a clinical scenario, not just restricting use of broad-spectrum drugs.
When done well, these discussions can be productive for everyone.
2. On a scale from 1 (not interested) to 10 (highly interested) how interested do you feel medical journal editors are in antimicrobial stewardship? What insights can you share on this topic?
Because antimicrobial resistance is a 10 (in the opinion of many editors), antimicrobial stewardship is also a high priority topic for medical journals. The top tier journals are most interested in novel investigations related to stewardship, especially in the form of multicenter, clinical trials.
JAMA published two outstanding stewardship related RCTs during the past few years, both related to using the electronic health record to improve antimicrobial prescribing. The first involved clinician education combined with audit and feedback . The second focused on behavioral interventions to improve prescribing . Generalizability (through use of the EHR system) was a major consideration and part of what gave these articles priority.
Observational studies, especially those that are from a single center, have lower priority but are still instructive and often well suited for more specialized audiences.
3. Expanding knowledge in the area of antimicrobial stewardship through new publications is important to the field, but what is more important – quality or quantity?
At this time, I would give the edge to quality but quantity is also important. Smaller, descriptive studies have their role and can sometimes provide the background for future interventional studies. That said, another descriptive study of a stewardship program is probably of less interest in 2016 than it might have been even a few years ago.
For authors, it’s important to highlight something novel, something instructive—why is this study different?
4. What advice do you have for clinicians and researchers pursuing publication of their work on antimicrobial stewardship?
My general advice for clinicians and researchers trying to publish their work on antimicrobial stewardship is to find the right home (the right journal). I like to say, “If you don’t publish it, it didn’t happen”. That may be an exaggeration but why not try to publish your work?
Practically speaking, it’s important to send manuscripts to the right journal. Read the table of contents and review previous articles related to stewardship to get a sense of what is and isn’t published in a particular journal. Previously published articles can serve as helpful models, especially those related to programmatic improvements, which might not fit into the standard “Introduction, Methods, Results, Discussion” format.
Novelty may be an issue for some articles. It’s just harder to publish a “me too” descriptive study. Time frame is also important. In a field that is moving so fast, recent work will have a better chance of acceptance. Try not to sit on results because you are “too busy”.
5. What do you think the future holds for the field of antimicrobial stewardship?
From a research standpoint, I expect to see a larger emphasis on implementation, especially in clinical settings outside of the acute care/inpatient side. For example, we have just started to explore the outpatient arena and subacute care, yet a large proportion of antimicrobial use occurs here.
Novel ways to practice stewardship in limited resource settings (places where infectious diseases consultation may not be readily available) will also be of interest. For better or worse, the future of stewardship is bright because we still have a long way to go in regards to antimicrobial overuse and misuse. The recent discussion about adverse effects related to quinolones is just the latest example for why stewardship efforts matter .
2. Barlam TF et al. Implementing An Antimicrobial Stewardship Program: Guidelines By The Infectious Diseases Society Of America And Society For Healthcare Epidemiology Of America. Clinical Infectious Diseases. 2016.
4. Gerber JS et al. Effect Of An Outpatient Antimicrobial Stewardship Intervention On Broad-Spectrum Antibiotic Prescribing By Primary Care Pediatricians, A Randomized Trial. Journal of the American Medical Association. 2013.
5. Meeker D et al. Effect Of Behavioral Interventions On Inappropriate Antibiotic Prescribing Among Primary Care Practices, A Randomized Clinical Trial. Journal of the American Medical Association. 2016.
I would like to express my sincerest thanks to Dr. Malani for her time and effort, which allowed for creation of this text.
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