Antimicrobial Stewardship Strategies

Antimicrobial Stewardship Strategies

By: Rasha Abdelsalam Elshenawy

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What is Antimicrobial Stewardship?

• Approximately 700,000 people die yearly from antibiotic-resistant infections, which is projected to surpass 10 million per year by 2050.
• The term ‘antimicrobial stewardship’ is encountered in a growing number and increasingly diverse range of contexts.
• The first article using the term ‘antimicrobial stewardship’ was first published by John E. McGowan Jr and Dale N. Gerding in the USA.
• They wanted to highlight that we should consider antimicrobials a precious, nonrenewable resource, using a term that incorporated both the appropriate use of antimicrobials and the avoidance of unnecessary use.
• Antimicrobial stewardship is a coherent set of actions that promote the use of antimicrobials in ways that ensure sustainable access to effective therapy for all who need it.
• The study “WHO AWaRe Classification for Antibiotic Stewardship: Tackling Antimicrobial Resistance – A Descriptive Study from an English NHS Foundation Trust Prior to and During the COVID-19 Pandemic” explores antibiotic prescribing trends for respiratory tract infections at a UK NHS Foundation Trust. Guided by the WHO AWaRe classification, it found increased use of “Watch” category antibiotics like azithromycin during the pandemic, emphasizing the importance of antimicrobial stewardship strategies in combating antimicrobial resistance.

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• As antimicrobial stewards, we need to carefully and responsibly manage antimicrobials.
• We suggest that it is best to view the collective daily actions within antimicrobial stewardship as a strategy.
• Actions that attempt to directly influence the behaviour of prescribers, patients, vets and farmers are often clearly aiming to either enable responsible antimicrobial use (e.g. decision support tools, audit and feedback) or to restrict inappropriate or unnecessary antimicrobial use (e.g. selective reporting of susceptibility testing, formulary restrictions).

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• These actions may be precisely termed ‘stewardship interventions in the context of inpatient hospital care.
• They vary depending on the actor but share many commonalities within a healthcare system at different levels.
• They are frequently coordinated by a multidisciplinary team who leads an antimicrobial stewardship programme that selects from a menu of potential interventions that are adaptable and customisable concepts.
• Antimicrobial stewardship is central to efforts to ensure access to effective antimicrobials for all who need them, today and tomorrow.

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Goals of Antimicrobial Stewardship:

• Primary Goal: to optimize clinical outcomes while minimising consequences of antimicrobial use Consequences, Toxicity, Selection of pathogenic organisms, and Emergence of resistant pathogens
• Secondary goal: to reduce healthcare costs without adversely affecting the quality of care

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Strategy and its Definition:

Antibiograms

• An antibiogram is a summary of the cumulative susceptibility of bacterial isolates to formulary antibiotics during a specified period. It represents the proportion of each bacterium susceptible to a given formulary antibiotic. Read More

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Automatic stop order

• Automatically applied to stop dates for antimicrobial orders when the duration of therapy is not specified. It can be individualized for specific antimicrobial classes, routes of administration and indications. Download Now

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Cascading microbiology susceptibility reporting

• A strategy of reporting antimicrobial susceptibility test results in which secondary (e.g., broader-spectrum, more costly) agents may only be registered if an organism is resistant to primary agents within a particular drug class (cascade reporting is one type of selective reporting). Download Now

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Checklists

• A checklist is a tool that outlines items that should be considered or steps that should be performed in a systematic order. Lists are used to ensure that essential tasks are reliably performed in a standardized fashion. Download Now

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Clinical decision support systems/computerized physician order entry

• Technological applications that assist the clinician in selecting and ordering tests and therapy. They can also be used to communicate information and generate reports. Download Now

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De-escalation and streamlining

• Changing broad-spectrum or multiple antimicrobials to narrow or target therapy, or discontinuing antimicrobials based on culture and susceptibility results. Download Now

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Disease-specific treatment guidelines/pathways/algorithms and associated order forms

• Evidence-based practice recommendations that incorporate local resistance patterns and institution-specific formulary antimicrobials into a guideline, treatment pathway, algorithm and order form. Download Now

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Dose optimization

• Review and individualization of antimicrobial dosing based on the characteristics of the patient, drug, and infection. Download Now

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Drug use evaluation/medication use evaluation

• Drug use evaluation (DUE) is a system of ongoing, systematic evaluation of drug use that will help ensure that medicines are used appropriately (at the individual patient level). Medication use evaluation (MUE) is similar to DUE, but it focuses on clinical outcomes and emphasizes improvements in medication use with a multidisciplinary approach. Download Now

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Empiric antibiotic prescribing guidelines

• Multidisciplinary, evidence-based recommendations done using local susceptibility data to standardize and improve the selection of initial therapy for common infectious diseases. Download Now

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Facilitation of appropriate and timely antimicrobial administration in severe sepsis/septic shock

• Prompt administration of appropriate antimicrobials (within the first hour of recognition of septic shock) improves outcomes. Interventions to facilitate prompt administration of appropriate antimicrobials and improve outcomes (including mortality) in patients with severe sepsis and septic shock. Download Now

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The policy of Formulary automatic substitution/therapeutic interchange policies

• The process whereby an order for a specific drug or dosing regimen is automatically changed or substituted according to preapproved procedures and conditions, without needing to consult the prescriber. Download Now

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Formulary restriction

• Restricted dispensing of targeted antimicrobials on the hospital’s formulary, according to approved criteria. The use of restricted antimicrobials may be limited to specific indications, prescribers, services, patient populations or a combination of these. Download Now

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The Formulary restriction with preauthorization

• Formulary review and streamlining involve limiting the number of antimicrobials available to the minimum needed for effective treatment, while eliminating agents with duplicate spectrums of activity. Download Now

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General antimicrobial order forms

• Forms used to single out and highlight prescriptions for anti-infectives to improve specific or overall antimicrobial use. Antimicrobial order forms are used to single out and highlight drugs for anti-infectives, with the goal of enhancing specific or general antimicrobial use Download Now

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Identification of inappropriate pathogen/antimicrobial combinations (“bug-drug mismatch”)

• Identification and modification of therapy in patients with positive cultures who are receiving ineffective treatment. “Bug-drug mismatch” refers to a situation in which the antimicrobial a patient is receiving does not provide adequate treatment (e.g., is resistant) for the microbiologically identified organism presumed to be causing the clinical infection. Download Now

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Improved antimicrobial documentation

• Adequate documentation of important aspects of antimicrobial prescribing to facilitate communication and decision-making within the health care team. Download Now

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Intravenous to oral conversion

• Intravenous to oral conversion (IV to PO) involves a policy or guideline for switching the route of administration after careful patient assessment. Download Now

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Prescriber education

• Education (formal or informal) to inform and engage prescribers and other health care professionals in stewardship activities and to improve antimicrobial prescribing. Download Now

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Preventing treatment of non-infectious conditions

• Stewardship interventions target specific situations when antimicrobials are not indicated but are frequently prescribed.
• This is to help decrease unnecessary antimicrobial therapy for non-infectious conditions. Download Now

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Promotion of timely and appropriate microbiologic sampling

• Implementing strategies to promote the appropriate and timely collection of cultures, ideally before antimicrobials started, to help direct therapy and avoid unnecessary prescribing. Download Now

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Prospective audit with intervention and feedback

• Prospective audit with intervention and feedback involves the assessment of antimicrobial therapy by trained individuals (usually physicians and pharmacists).
• This is to make recommendations to the prescribing service in real-time when treatment considered suboptimal. Download Now

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Scheduled antimicrobial reassessments (“antibiotic time-outs”)

• An antibiotic “time out” a term used by the Centers for Disease Control and Prevention.
• Additionally, lt listed as a critical intervention for improving antibiotic use.
• It involves a formal reassessment by the most responsible physician at a predetermined point (often 48 to 72 hours after the initiation of therapy) to determine the continued need for and choice of antimicrobial. Download Now

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Strategic microbiology results reporting

• The use of strategic and selective culture and susceptibility reporting and inclusion of interpretive comments to help clinicians better understand culture results and direct appropriate and cost-effective antimicrobial prescribing. Download Now

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Surgical antibiotic prophylaxis optimization

• Appropriate administration of antibiotics in the perioperative period significantly reduces the incidence of surgical site infections for many types of surgery. Read More & Download Now

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Systematic antibiotic allergy verification

• Systematic allergy assessment with appropriate documentation and interpretation for all patients—or targeting those prescribed antimicrobial agents—could help optimize the selection of antimicrobial agents and avoid broad-spectrum or more toxic alternatives. Download Now

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Targeted review of patients with Clostridium difficile infection

• Review of positive blood cultures to assess empiric therapy for appropriateness and de-escalation once culture and susceptibility results are available. Download Now

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Targeted review of redundant therapy or therapeutic duplication

• Identification and intervention for patients prescribed potentially redundant/duplicative therapy (i.e., antimicrobials with an overlapping spectrum of activity). Download Now

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Therapeutic drug monitoring (with feedback)

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