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.
