5 Things Worth Knowing About Antibiotic Stewardship

SEPTEMBER 02, 2015
Antimicrobial stewardship programs are being incorporated into the global health care landscape to combat the spread of drug-resistant pathogens and preserve existing drugs.

If you were to search the term “steward” online, you would find that one definition is “a person whose responsibility it is to take care of something.” So, in the most fundamental way, antimicrobial stewards are people who take care of antibacterial, antiviral, antiparasitic, or antifungal drugs.

How does a person take care of a drug? Well, current guidelines say that the primary goal of antimicrobial stewardship is to “optimize clinical outcomes while minimizing unintended consequences of antimicrobial use, including toxicity, the selection of pathogenic organisms (such as Clostridium difficile), and the emergence of resistance,” with a secondary goal to “reduce health care costs while maintaining the highest possible quality of care."1

Considering these broad goals and the vast number of activities that fall under this umbrella, one way to simplify antimicrobial stewardship is by placing things into 2 categories: what is being done and what can be done.

This is where antimicrobial stewardship programs come into the picture to a large degree. These programs aim to achieve the aforementioned goals by working to optimize existing practices while selecting, implementing, and providing oversight on new activities and interventions.

Here are 5 important things to know about this field:
 
1. Antimicrobial stewardship is here to stay.
We are in an era where, at times, the drugs in our antimicrobial armamentarium have virtually no clinical utility against the bacteria causing the infection.2 With little assistance in sight from the antimicrobial drug development pipeline, antimicrobial stewardship and infection prevention are key to conserving the miracle of antibiotics.3

In turn, substantial commitments are being made to implement and expand antimicrobial stewardship initiatives. One example of this is the US Veterans Health Administration Directive 1031, which establishes a policy for such activities at all 152 VA medical centers.4
 
2. Antimicrobial stewardship is a team sport with the patient at the center.
A pharmacist and physician with advanced training in infectious diseases are identified as 2 core members of an antimicrobial stewardship team. But without support and collaboration from prescribers, nurses, information technologists,
administrators, laboratory personnel, and other health care professionals, efforts are destined to fall short of their potential.

When it comes to antimicrobial stewardship it’s teamwork that makes the dream work. And when the dream works, the patient wins.
 
3. Antimicrobial stewardship is not synonymous with infectious diseases.
Antimicrobial stewardship efforts aim to conserve agents used for treating infectious diseases, but the implementation of these initiatives oftentimes includes analysis of current practices followed by education, system-wide process changes, and quality assurance monitoring. 

As a result, the field of antimicrobial stewardship goes beyond clinical infectious diseases to include elements of operations, education, quality, administration, information technology, and more.
 
4. Everyone is an antimicrobial steward.
When you think of antimicrobial stewards, prescribers, pharmacists, nurses, and other health professionals likely come to mind. But it doesn’t stop there.

We are all stewards of antibiotics, and your role in promoting awareness and discouraging inappropriate antimicrobial use extends outside of the health care facility. So, when you hear that your friend gave her sister expired ciprofloxacin from 8 years ago for a “snort, sniffle, and sneeze” most likely representing a viral upper respiratory infection for which antibiotics will not provide benefit,5 please don't ignore it.

As health care professionals, pharmacists have a responsibility to educate others that antimicrobials can be toxic, should not be taken without proper supervision, and are a precious resource. It may be additionally helpful to direct patients to reliable online sources of information, such as the US Centers for Disease Control and Prevention website.
 
5. We still have a lot to learn about antimicrobial stewardship.
The amount of literature in the field of antimicrobial stewardship has expanded in recent years,6 but few of the recommendations in current guidelines are at the level of A-I (i.e., good evidence from at least 1 properly randomized, controlled trial).1 On top of this, each institution has its own unique combination of resources and problems.

As a result, there is a substantial need for well-designed studies that assess a variety of issues within different practice settings. Some areas with the most significant need of further study include pediatric populations and long-term care and outpatient settings.6
 
The views expressed in this article are those of the author and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the US government.

References:
1. Dellit TH et al. 2006 Infectious Diseases Society of America and Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clinical Infectious Diseases. 2007; 44:159-177.
2. Antibiotic resistance threats in the United States, 2013. US Department of Health and Human Services, Centers for Disease Control and Prevention. Available at: http://www.cdc.gov/drugresistance/pdf/ar-threats-2013-508.pdf. Accessed 25th August 2015.
3. Boucher HW et al. 10 x 20’ progress – development of new drugs active against gram-negative bacilli: an update from the infectious diseases society of America. Clinical Infectious Diseases. 2013; 56(12):1685-94.
4. VHA Directive 1031: Antimicrobial stewardship programs. Department of Veteran Affairs, Veterans Health Administration. Jan 22, 2014. Available at: http://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=2964. Accessed 20 August 2015.
5. Snort Sniffle Sneeze: no antibiotics please. Centers for Disease Control and Prevention TV. Available at: http://www.cdc.gov/cdctv/diseaseandconditions/lifestyle/no-antibiotics-please.html. Accessed 25th August 2015.
6. Santibanez M, Veulens MV, Jenistova T, Aragon L, Gauthier TP. Characteristics of primary literature in the field of antimicrobial stewardship, 2000-2013. Infection Control and Hospital Epidemiology. 2015; 36(5):616-18.

Timothy P. Gauthier, PharmD, BCPS-AQ ID
Timothy P. Gauthier, PharmD, BCPS-AQ ID
Timothy P. Gauthier, PharmD, BCPS-AQ ID, graduated from Northeastern University's School of Pharmacy in 2008 and then completed 2 years of post-graduate residency training. Since then he has been engaged in clinical infectious diseases pharmacy and antimicrobial stewardship teaching, practice and research. You can find him on social media @IDstewardship.
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