Antimicrobial Stewardship Programs 

Rob Owens, PharmD

Clinical Specialist, Infectious Diseases, Co-Director, Antimicrobial Stewardship Program, Maine Medical Center, Portland, Maine

   Antimicrobial stewardship programs have become more popular as a growing number of studies have demonstrated the overuse of antimicrobials in many clinical settings. Stewardship programs provide an option to improve antimicrobial prescribing for both community-based and hospital-based healthcare professionals. The primary goal of an antimicrobial stewardship program is to optimize clinical outcomes while minimizing the unintended consequences of antimicrobial therapy (eg, toxicity, selection of pathogenic organisms such as Clostridium difficile and antimicrobial resistance). Antimicrobial stewardship programs can also decrease total antimicrobial use and overall treatment cost.¹

   Although physicians and patients are often reassured by the use of antimicrobial therapy, antimicrobial resistance is increasing precipitously, and the number of effective antimicrobial agents is declining. Antibiotic prescribing has become increasingly complex, and many patients receive inappropriate antimicrobial therapy. Computerized decision support tools and human decision support can help prescribers to overcome barriers to effective prescribing, such as interpreting test results (eg, minimum inhibitory concentration values), understanding guidelines and local resistance patterns, choosing an effective route and duration of administration, and drug interactions and adverse effects. The key to success is to integrate information from several different sources within the healthcare facility, including the pharmacy and therapeutics committee, hospital administration, infectious disease specialists, clinical pharmacists, critical care physicians, surgeons, and others. An effective antimicrobial stewardship program might encompass several specific strategies to increase the appropriate use of antibiotics, including physician education, guideline development and dissemination, monitoring antibiotic deescalation or switching, and dose optimization. Passive or restrictive approaches to antimicrobial control (eg, automatic stop orders and limited formulary) have generally not been effective at improving outcomes. Antimicrobial stewardship programs have been shown to significantly reduce challenging infections, such as C difficile, while also decreasing antibiotic use.²

   Antimicrobial stewardship is important in maintaining the long-term effectiveness of our available treatment options, but is only one component of an overall strategy to reduce the spread of antimicrobial resistance. Other factors, including environmental control and infection control, are also important in preserving the efficacy of antimicrobial agents. In addition, recent studies have demonstrated the efficacy and safety of shorter courses of therapy for certain infections, which have been accompanied by reductions in antimicrobial resistance and overall antimicrobial use. Optimal dosing of all antimicrobial agents is essential, as well as streamlining and deescalating therapy after the results of culture tests are known.

References

1. Dellit TH, Owens RC, McGowan JE Jr, et al. Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clin Infect Dis. 2007;44:159-177.

2. Valiquette L, Cossette B, Garant MP, et al. Impact of a reduction in the use of high-risk antibiotics on the course of an epidemic of Clostridium difficile-associated disease caused by the hypervirulent NAP1/027 strain. Clin Infect Dis. 2007;45(suppl 2):S112-S121.