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Sunday, June 17, 2012

Antimicrobial Stewardship

The issue of continuously increasing antimicrobial resistance has necessitated actions on the part of the society in general and stakeholders in antibiotic use in particular, to create pathways to minimise antimicrobial resistance. A particular programme which has attracted worldwide attention currently is the ‘Antimicrobial Stewardship programme’.
The term ‘antimicrobial stewardship’ is defined as the optimal selection, dosage, and duration of antimicrobial treatment that results in the best clinical outcome for the treatment or prevention of infection, with minimal toxicity to the patient and minimal impact on subsequent resistance. With the emerging knowledge of antimicrobial residues in the environment and the non-human use of antimicrobials contributing to antimicrobial resistance, an all round multidisciplinary approach involving also the veterinarians and environmentalist would in effect result in a really reduced existence of resistant bacteria. Such an `Augmented Antibiotic Stewardship Programme’ (AASP) is thus a need of the hour.
Studies have established a strong relationship between antimicrobial use and resistance. Therefore prescribing antimicrobial therapy when and only when it is beneficial to the patient, targeting therapy to the desired pathogens, and using the appropriate drug, dose, and duration are important contributions towards reducing resistance. Overuse and misuse must be decreased to reduce the selective pressure that results in the spread of resistance.
Current ‘Antimicrobial stewardship programmes’ have evolved as a means for clinicians to optimize antimicrobial use in hospitals in accordance with consensus recommendations. The literature describes a multitude of strategies ranging from many individual interventions (e.g., formulary manipulations, dosing recommendations, and academic detailing) to less common but more broad and programmatic approaches (e.g., prior-approval programs, concurrent review and feedback).All of these strategies seem to impact on appropriate antimicrobial use, clinical outcomes, antimicrobial resistance and costs.
Antimicrobial stewardship programs, whose goal is to improve the use of antimicrobials at the institutional level, have been successful. Two dominant strategies exist for these programs -- prior approval, and concurrent review and feedback. Many issues, including measurable outcomes, barriers, funding, and personnel, must be identified before a program is implemented. studies indicate that oversight of antimicrobial use (whether restrictive or more subtle through concurrent review and feedback) has had a measurable impact on appropriateness of antimicrobial use, antimicrobial consumption, and/or expenditures, resistance rates, infection rates, and clinical outcomes.
Antimicrobial stewardship programs should have definite goals ensuring that performance outcomes are easily measured and relevant. Financial issues will automatically resolve themselves as ‘money saved is money gained’.
Measured outcomes and performance indicators include recommendation acceptance rates, adherence rates with antibiotic use guidelines, microbiologic and clinical response rates, frequency of antibiotic re-administration within 7 days, adverse drug events, time to approve antimicrobials and time to their administration to the patient, hospital readmission rates related to infectious diagnoses, length of hospital stay, mortality rates, antimicrobial resistance rates, infection rates, antibiotic expenditures and use rates measured in terms of defined daily dose, associations between antimicrobial use and resistance or infection rates, overall hospital costs, and costs directly attributable to the infectious process. Outcome measurements should be institution specific and discussed and agreed on before the program is implemented. Surveys may be used before the introduction of an antimicrobial stewardship program and should be used as a continuing tool. Depending on the programme, population-based antimicrobial use and resistance correlation can also be studied.  Interrupted time series with segmented regression analysis can result in a sophisticated means of measuring the true impact of interventions on antimicrobial use.
When considering the `Augmented Antibiotic Stewardship Programme’ (AASP), involvement of appropriate management of bio-medical waste and hospital waste water which create environmental residues that generate resistant bacteria is a must and proper guidelines for this must be created.   Veterinarians should be considered a must as their prescriptions also constitute a risk to development of antimicrobial resistance and actually several Antibiotic Stewardship Programme guidelines could be common to them.
 Barriers/ Impediments
The perception of threatened autonomy can be a significant impediment to the effort.  This can be resolved by creating Multidisciplinary Committees. Being proactive and not reactive is also very helpful, e.g. provide program's antibiotic guidelines to all faculty members and important administrative personalities for review to gain consensus before they are circulated for implementation. Monitoring of ‘pseudo-outbreaks’ (i.e. increased rate of infections represented by clinicians attempting to justify the use of a particular restricted antimicrobial by documenting in the medical record that infection existed) is also crucial to the success of the programme.