Antimicrobial Stewardship

https://doi.org/10.1016/j.amjmed.2006.04.003Get rights and content

Abstract

Antimicrobial stewardship is a key component of a multifaceted approach to preventing emergence of antimicrobial resistance. Good antimicrobial stewardship involves selecting an appropriate drug and optimizing its dose and duration to cure an infection while minimizing toxicity and conditions for selection of resistant bacterial strains. Studies conducted over the years indicate that antibiotic use is unnecessary or inappropriate in as many as 50% of cases in the United States, and this creates unnecessary pressure for the selection of resistant species. Because the pharmaceutical industry pipeline for new antibiotics has been curtailed in recent years, and it may be ≥10 years before important new antibiotics to treat certain resistant bacteria find their way to market, a premium has been set on maintaining the effectiveness of currently available agents. Several strategies, including prescriber education, formulary restriction, prior approval, streamlining, antibiotic cycling, and computer-assisted programs have been proposed to improve antibiotic use. Although rigorous clinical data in support of these strategies are lacking, the most effective means of improving antimicrobial stewardship will most likely involve a comprehensive program that incorporates multiple strategies and collaboration among various specialties within a given healthcare institution. Computer-assisted software programs may be especially useful in implementing these comprehensive programs. The antimicrobial stewardship program at the Hospital of the University of Pennsylvania, which has been shown to improve appropriateness of antibiotic use and cure rates, decrease failure rates, and reduce healthcare-related costs, is used as an example in support of this multifaceted, multidisciplinary approach. At this time, data from well-controlled studies examining the effect of antibacterial stewardship on emergence of resistance are limited, but available data suggest that good antibiotic stewardship reduces rates of Clostridium difficile–associated diarrhea, resistant gram-negative bacilli, and vancomycin-resistant enterococci.

Section snippets

Conceptual framework for antibiotic use

Antibiotic resistance is a multifaceted problem requiring multifactorial interventions to prevent its emergence and further spread. As schematically illustrated in Figure 2, these factors include strategies to reduce reservoirs of resistant bacteria, improved diagnostics to identify the etiology of infections and help direct therapy, development of new antibiotics and vaccines, improved use of current vaccines, infection-control measures to prevent transmission of resistant species

Strategies to improve antibiotic use

Several interventions promote the judicious use of antibacterial agents including education, formulary restriction, prior approval, streamlining, antibiotic cycling, and computer-assisted programs.

Comprehensive control: The Hospital of the University of Pennsylvania program as a paradigm

Healthcare institutions often combine a number of the above-mentioned individual strategies to create a more comprehensive program for antimicrobial management and resistance control (Figure 3).12, 13 Because these programs involve multiple factors or individual strategies and typically entail collaboration between different groups within and sometimes outside of the institution, they are often referred to as multifaceted and multidisciplinary programs. Computer-assisted software programs

Can antibacterial stewardship limit emergence of resistance?

Unfortunately, studies in this area are somewhat sparse, and available reports may have study-design shortcomings such as selection bias, insufficient power, inadequate preobservation and postobservation datum points, and failure to deal with confounders. Of equal importance, antibiotic stewardship programs are generally implemented at a time of crisis, e.g., in response to emergence of resistance in a given institution or ward. Because multiple interventions are typically implemented

Summary

The antibiotic armamentarium is decreasing due to increasing emergence of bacteria resistant to currently available agents, coupled with a dwindling pipeline for new drugs. New agents are urgently needed, but as noted by Dennis Maki in 1998 at the annual meeting of the IDSA, “The development of new antibiotics without having mechanisms to insure their appropriate use is much like supplying your alcoholic patients with a finer brandy.” Antibiotic stewardship should extend the effectiveness of

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