Antimicrobial Stewardship

Introduction - Scope of the problem Recommended interventions and tools Premier's solutions Guidelines and references Stakeholders

Introduction - Scope of the problem

It has been recognized for nearly five decades that up to 50 percent of antimicrobial use is inappropriate. The consequences of inappropriate use include increased microbial resistance, toxicity, hospital lengths of stay, as well as increased costs to patients, hospitals and payors. Efforts to bring improved appropriate use and reduce resistance have come from many stakeholders,  including professional societies; government and accrediting organizations; pharmaceutical companies; and a number of state public and private initiatives. Most recently, Congress has proposed legislation addressing antimicrobial usage. The Strategies To Address Antimicrobial Resistance (or STAAR) Act will strengthen federal antimicrobial resistance surveillance, prevention and control, and research efforts as well as enhance the collection of critical information on the use of antibiotics in humans and animals.

The greatest success can be achieved with an institution-wide comprehensive antimicrobial management program that has a multidisciplinary approach and focuses on appropriate selection, dosing, route and duration of antimicrobial therapy.  

The goal of all these public and private initiatives is to challenge practitioners to re-evaluate their practices and implement institution-wide policies and procedures regarding appropriate antimicrobial utilization. Antimicrobial stewardship programs (ASPs) are the current standard for meeting these challenges. Such programs seek to optimize antimicrobial selection, dosing, timing and durations of therapy in order to reduce resistance, reduce toxicities and enhance patient outcomes. 

There are many resources for hospitals to use as guides for implementing new ASPs or enhancing existing ones. A brief overview of these recommended interventions is provided here with links to selected guidelines and references.

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Recommended interventions and solutions

Core components of antimicrobial stewardship programs

• Prospective audit with intervention and feedback
  • Concurrent and direct education to prescribers at a patient-specific level on local resistance patterns, clinical literature, antimicrobial selection, dosing and duration of therapy.
  • Education has historically been performed by physicians or clinical pharmacists.
• Formulary restriction and pre-authorization, two optimal methods:
  • Closed formulary with a defined set of available agents.
  • Pre-authorization with prescriber justification.

Suggested supplemental components of
antimicrobial stewardship programs

• Education – education is essential but only marginally effective in the absence of complimentary clinical interventions.
• Multi-disciplinary teams – including physicians, pharmacists, infection control professionals and microbiologists.
• Guidelines and clinical pathways – evidence based practice guidelines incorporating local microbiology data.
• Antimicrobial order forms – requiring physician justification for antimicrobial utilization.
• De-escalation of therapy – utilizing the most narrow spectrum drug to treat a specific infection based upon culture results.
• Dose optimization – using patient specific criteria in conjunction with pathogen
  specific criteria to optimally dose antimicrobials.
• Computer surveillance and decision support – automating surveillance of antimicrobial utilization, resistance patterns and identification of hospital-acquired infection.
• Monitoring process and outcome measures – both are key elements to assessing the impact and outcomes of stewardship programs.

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Premier's solution for optimizing antimicrobial usage - SafetySurveillor™ - Pharmacy

• Premier's SafetySurveillor™ – Pharmacy is a web-based tool to assist clinicians and pharmacists with optimizing antimicrobial usage, enhance outcomes, and reduce the costs associated with inappropriate use.

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Guidelines and references

• IDSA-SHEA The Infectious Disease Society of America and the Society Healthcare Epidemiology of America Guidelines
  IDSA-SHEA Guidelines for Institutional Programs for Antimicrobial Stewardship Clinical Infectious Diseases. 2007;44(15 Jan):159-177 http://www.journals.uchicago.edu/doi/pdf/10.1086/510393
• CDC’s fact sheet
  CDC Fact Sheet on Appropriate Antimicrobial use for Hospitalized Patients. http://www.cdc.gov/drugresistance/healthcare/ha/12steps_HA.htm
• SIDS recommendations
  Society of Infectious Diseases Pharmacist review and recommendations for implementing antimicrobial stewardship programs. Pharmacotherapy. 2004;24(7):896-908.
  Download abstract (.doc) (25 KB)
• Clinical microbiology review
  Comprehensive review of the rationale, structure and outcomes of antimicrobial stewardship programs in health-systems. McDougal et al. Clinical Microbiology Reviews. 2005;18:636-656. Download McDougal (.pdf) (215 KB)
• Automated surveillance tool for antimicrobial stewardship
  Impact of a computerized clinical decision support system on reducing inappropriate antimicrobial use: A randomized controlled trial. McGregor et al., Journal of American Medical Informatics Association. 2006;13:378-384.
  Download McGregor (.pdf) (107 KB)

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Stakeholders

Selected organization with resources and guidelines to support appropriate antimicrobial utilization.

Professional societies

APIC - Association for Professionals in Infection Control and Epidemiology
http://www.apic.org/

ASHP - American Society of Healthcare Pharmacists http://symposia.ashp.org/cemantimicrobial/overview.asp

IDSA - Infectious Disease Society of America
http://w.idsociety.org/staaract.htm

SHEA - Society for Healthcare Epidemiology of America
http://www.shea-online.org/publications/shea_position_papers.cfm

SIDP - Society of Infectious Disease Pharmacists
http://www.sidp.org/

Premier Safety Institute - guidelines

• Guidelines: http://www.premierinc.com/quality-safety/tools-services/safety/topics/guidelines/other.jsp#antimicro-pro
• Surveillance and antimicrobials: http://www.premierinc.com/quality-safety/tools-services/safety/topics/guidelines/antimicrobials.jsp

   Government agencies and accrediting organizations

CDC - Centers for Disease Control and Prevention http://www.cdc.gov/drugresistance/healthcare/default.htm

CMS - Centers for Medicare and Medicaid Services
http://www.cms.hhs.gov/center/pharmacist.asp

TJC - The Joint Commission
http://www.jointcommission.org/

   Congressional activity
    Strategies To Address Antimicrobial Resistance Act http://www.idsociety.org/staaract.htm

Senate Version
http://www.idsociety.org/WorkArea/showcontent.aspx?id=8368

House Version
http://www.idsociety.org/WorkArea/showcontent.aspx?id=7002

 

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