New Guidelines for Antibiotic Stewardship Programs

Antibiotic resistance is a growing concern perpetuated by inappropriate antibiotic use, which encompasses antibiotic nonadherence and being prescribed an incorrect antibiotic dose or incorrect antibiotic based on the diagnosis.¹

At least 2 million illnesses and 23,000 deaths each year are due to antibiotic resistance.¹ In 2015, the White House released the National Action Plan for Combating Antibiotic-Resistant Bacteria, detailing steps to combat resistant bacteria and advocate for the implementation of antibiotic stewardship programs (ASPs) in all acute-care hospital settings by 2020.

ASPs have been shown to improve patient outcomes, reduce adverse events like Clostridium difficile infection, improve rates of antibiotic susceptibilities to targeted antibiotics, and optimize resource use across the continuum of care.³ The paucity of new antibiotics reaching the market to combat resistant pathogens has made the appropriate use of current therapies a priority.

A multidisciplinary expert panel comprised of the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America recently released new antibiotic stewardship guidelines focusing on preauthorization of antibiotics or prospective review, facility-specific guidance, syndrome-specific stewardship, and other recommendations targeted at optimal antibiotic use to reduce the occurrence of resistant pathogens.

The new guidelines consist of 28 recommendations divided into the following 5 categories:

1. Interventions

Preauthorization and/or prospective audit and feedback are recommended as a foundational component of any ASP. Both of these interventions have their advantages and disadvantages.

Preauthorization is a method for improving antibiotic use by mandating physicians to get approval prior to prescribing certain antibiotics, which has been associated with significant decreases in the use of restricted agents and associated costs, as well as improved optimization of empiric therapies. However, this intervention may delay the time to appropriate therapy and is real-time resource intensive.

Prospective audit and feedback, on the other hand, engages providers after an antibiotic has been prescribed and makes more clinical data available for recommendations. However, this intervention may take longer to achieve reductions in targeted antibiotic use, and prescribers may be unwilling to change therapy when a patient is doing well.

2. Antibiotic Administration Optimization

Hospital implementation of pharmacokinetic (PK) monitoring and adjustment programs for aminoglycosides are recommended because they’ve been shown to reduce costs and decrease adverse effects. Individualized PK monitoring and adjustment of aminoglycoside dosing compared with standard dosing is associated with increased likelihood of obtaining serum concentrations within therapeutic range. Moreover, reductions in nephrotoxicity, hospital length of stay, and mortality have been observed in some studies.

3. Microbiology and Laboratory Diagnostics

Rapid diagnostic testing in conjunction with conventional culture and routine reporting on blood specimens, combined with active ASP support and interpretation, is recommended to optimize antibiotic therapy and improve clinical outcomes. Since the accessibility of rapid diagnostic tests is anticipated to grow, it’s recommended that ASPs develop processes and interventions to help prescribers in interpreting and responding appropriately to results. The use of rapid molecular assays and mass spectrometry to identify bacterial species and susceptibility in blood cultures has been linked to improvements in time to initiation of appropriate antibiotic therapy, rates of recurrent infection, mortality, length of stay, and hospital costs.

4. Measurement Analysis

Measuring antibiotic costs based on prescriptions or administrations instead of purchasing data is recommended to assess the impact of ASPs and interventions. It’s been noted that ASPs result in cost savings for facilities; thus, it’s imperative to assess program costs in addition to measuring antibiotic use as a way to validate continued ASP activities.

5. Stewardship in Special Populations

Implementation of ASP strategies in nursing homes and skilling nursing facilities is recommended to help reduce unnecessary antibiotic use, since these facilities are significant reservoirs for multidrug-resistant bacteria. Developing approaches to improve antibiotic use is important and must involve point-of-care providers to be successful.

To combat increased antibiotic resistance, it’s imperative for health care professionals to work together to take the necessary steps and make changes that will improve outcomes for patients. Every health care facility is capable of instituting an ASP, which is of central importance to the future of public health.

References

• CDC. About antimicrobial resistance. cdc.gov/drugresistance/about.html. Updated September 8, 2015. Accessed July 14, 2016.
• The White House. National Action Plan for Combating Antibiotic-Resistant Bacteria. whitehouse.gov/sites/default/files/docs/national_action_plan_for_combating_antibotic-resistant_bacteria.pdf
• Barlam TF, et al. Implementing an Antibiotic Stewardship Program: Guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. Clin Infect Dis. 2016: ciw118v1-ciw118.