| Antimicrobial Stewardship Programs Discussion |
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Antimicrobial Stewardship Programs Rob Owens, PharmD Discussion Dr Kollef: My take on stewardship is that the focus is really on the back end of trying to minimize resistance. The hospital’s goal is to keep costs down. One of the things that has not been emphasized is that if you look upfront, if the patient is treated with the wrong drug, they are more likely to die, but they are also probably going to have higher costs, because the main driver of cost is the length of hospital stay. You mentioned that if they are not dosed appropriately they may have a longer time until they respond, which might mean a longer time in the hospital. There are some studies in methicillin-resistant Staphylococcus aureus, sepsis, and fungal infections that show that if you treat patients upfront with an aggressive appropriate therapy that costs are lower because the length of stay is less. Thus there are really 2 ends to the stewardship issue. I think the upfront issue is more straightforward than the back-end issue, which is where a lot of this is directed. An issue that we also face is patients who come from nursing homes and long-term acute-care facilities. There is often very little infection control or antimicrobial stewardship, and the quinolones are heavily used in those environments. Dr Owens: And then when they come to the emergency department, they often receive a quinolone again because they have a so-called urinary tract infection. We are trying to address front-end prescribing with urinary tract infections. We could also apply the same principles of stewardship to long-term care settings. It is a matter of resources. There are certainly opportunities there to improve antibiotic use. Dr Kollef: Do you still see a lot of people using combinationns—for example, cefepime and metronidazole—for pneumonia, thinking that they are treating the aspiration? Dr Owens: No, we have been good about that. Bacteroides fragilis does not routinely cause pneumonia, so why is metronidazole on board? Cephalosporins cover the upper airway anaerobes sufficiently, in my opinion, so we have treated with monotherapy there. Dr Kollef: For medical students and residents, this is often what they are still being taught—that if I have got pneumonia I have got to treat with both to cover for the aspiration and the anaerobes. Dr Owens: You see piperacillin/tazobactam used a lot for that, specifically for anaerobes when it is not necessary, so there is a good opportunity for stewardship there.
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