Antibiotic stewardship

Antibiotic stewardship is a coordinated effort to evaluate and improve the prescribing of antibiotics by implementing measures that encourage the proper selection and use of antibiotic regimens. The development of antibiotic resistance with risks of creating multidrug-resistant organisms is one of the largest global and public health threats and can lead to increased morbidity and mortality. Antibiotic stewardship programs (ASPs) are composed of infectious disease consultants, pharmacists, microbiology laboratory staff, and nurses who develop and implement strategies to minimize the harm that can result from antibiotic use while also maximizing the benefits of antibiotic treatment. These strategies may include educational resources; surveillance, monitoring, and reporting of various indicators of adequate antibiotic usage (e.g., prescription rates, antibiotic resistance trends, adverse events); and antibiotic audits and feedback. Expected outcomes of ASPs include reduction in antibiotic resistance rates and improvement of clinical outcomes (e.g., reduction in adverse event rates).

• 30% of antibiotic prescriptions are unnecessary and/or suboptimal. ^[1][2]
• Antibiotic resistance has been estimated to cause:
  • 23,000 deaths per year in the United States ^[2]
  • > 4 million deaths in 2019 globally ^[3]
• Adverse events related to antibiotics
  • Cause 143,000 visits to the emergency department per year ^[2]
  • Occur in 20% of patients who receive antibiotics while hospitalized ^[1]

Epidemiological data refers to the US, unless otherwise specified.

ASP components may vary according to the health care setting.

Multidisciplinary team ^[1][4]

• Infectious diseases consultants
• Pharmacists (often trained in infectious diseases)
• Microbiology laboratory staff
• Nurses

Educational resources ^[1][4]

• Lectures and educational material for health care workers and patients
• Creation and/or distribution of guidelines and protocols for common infectious diseases

Antibiotic audits and feedback ^[1][4]

• Preauthorization: Approval, commonly from an expert in infectious disease, is required before prescribing certain antibiotics.
• Prospective audit and feedback: expert review of antibiotic therapy after it has been prescribed

Surveillance and monitoring ^[1][4]

• Antibiotic prescribing metrics
• Antibiotic resistance trends
• 30-day mortality rates
• Antibiotic-related adverse events

Reporting ^[1][4]

• Regular updates to clinical teams and hospital leadership
• Reporting to the National Healthcare Safety Network through their Antimicrobial Use and Resistance module is encouraged. ^[1]

Department-specific interventions ^[1][4]

• Microbiology laboratory
  • Stratified antibiograms
  • Selectively reporting antibiotic susceptibility data
  • Explanation of culture results
• Pharmacy
  • Changing the route of therapy from IV to oral
  • Alerts for duplicate therapy
  • Antibiotic automatic stop orders
  • Regimen optimization
  • Therapeutic drug monitoring
• Nursing
  • Use of proper techniques and indications for collecting cultures
  • Antibiotic reviews
  • Encouraging IV to oral transitions

Successful antibiotic stewardship programs utilize a multidisciplinary approach.

Infection-based interventions ^[1]

General principles

• Ensure adequate differential diagnosis (e.g., bacterial vs. viral etiologies or noninfectious causes).
• Optimize antibiotic therapy duration based on guidelines.
• Avoid unnecessary antipseudomonal antibiotic or MRSA coverage unless patients have risk factors, e.g.:
  • Risk factors for MRSA
  • Risk factors for Pseudomonas aeruginosa
• Encourage age-appropriate immunizations. ^[5]

Unnecessarily prolonged antibiotics courses can lead to patient harm and should be avoided.

Common infectious syndromes

• Sepsis
  • Initiate empiric antibiotic therapy based on local antibiograms.
  • Implement protocols for prompt initiation of antibiotics.
  • Tailor or stop therapy early when appropriate.
• Community-acquired pneumonia
  • Utilize viral studies (e.g., respiratory viral panel) and/or procalcitonin to assess the likelihood of bacterial etiology.
  • Test for MRSA colonization in patients with risk factors for MRSA to de-escalate empiric therapy.
  • Obtain respiratory cultures to tailor therapy.
• Urinary tract infection
  • Obtain urine cultures only in patients with symptoms of UTI.
  • Do not initiate antibiotics in patients with asymptomatic bacteriuria unless indicated; see “Asymptomatic bacteriuria” in “Urinary tract infections.”
• Skin and soft tissue infection
  • Implement criteria for determining purulent vs. nonpurulent infections.
  • Avoid MRSA coverage in uncomplicated nonpurulent infections in patients without MRSA risk factors.

Antibiotic stewardship programs support effective sepsis management by optimizing antibiotic use and improving patient outcomes, countering the misconception that such programs hinder care. ^[1]

Clinical outcomes ^[1][2][4]

• Reduction of adverse events, including:
  • Clinical failure
  • Clostridiodes difficile infections
  • 30-day mortality
  • Allergic reactions
  • See also “Overview of antibiotic therapy.”
• Decrease in hospital readmissions
• Decrease in length of hospital stay

System- and program-level outcomes ^[1][2][4]

• Reduction in antibiotic resistance rates through:
  • Decreasing initiation of unnecessary antibiotics
  • Targeting therapy to the isolated organism
• Optimization of antibiotic treatment
  • Ensuring appropriate antibiotic and dose selection
  • Avoiding prolonged durations of therapy
  • Selecting the correct route of administration
• Improved utilization of health care resources
• Cost savings for health care systems

Effective antibiotic stewardship programs reduce adverse drug events and antibiotic resistance rates.

Antibiotic stewardship in children ^[5]

• Include specialists with expertise in pediatrics in the ASP multidisciplinary team.
• Implement ASPs in pediatric units, including neonatal ICUs, as well as the ambulatory setting.

20% of pediatric clinic visits result in a prescription for antibiotics, and ≥ 50% of those prescriptions are unnecessary. ^[5]

Antibiotic stewardship in immunocompromised patients ^[4]

Facilities with a large population of immunocompromised patients should include ASP programs with the following:

• ASP multidisciplinary team: includes specialists with expertise in transplant and malignancies ^[6]
• Interventions for appropriate prescribing of antifungal therapy, e.g.:
  • Fungal diagnostics, including fungal markers (e.g., β-D-glucan assay)
  • Education
• Facility-specific guidelines for:
  • Management of neutropenic fever
  • Antibiotic prophylaxis (e.g., in the setting of neutropenia, transplantation) ^[6]