Antimicrobial stewardship

Antimicrobial stewardship (AMS) is the systematic effort to educate and persuade prescribers of antimicrobials to follow evidence-based prescribing, in order to stem antibiotic overuse, and thus antimicrobial resistance. AMS has been an organized effort of specialists in infectious diseases,both in Internal Medicine and Pediatrics with their respective peer-organizations, hospital pharmacists, the public health community and their professional organizations since the late 1990s. It has first been implemented in hospitals. In the U.S., AMS has largely been voluntary self-regulation in the form of policies and appeals to adhere to a prescribing discipline. At hospitals, this may take the form of an antimicrobial stewardship program. As of 2014, only the state of California has made AMS mandatory by law.

Definition

AMS, per the 2007 definition of the Society for Healthcare Epidemiology of America (SHEA), is a "set of coordinated strategies to improve the use of antimicrobial medications with the goal to

History

Antimicrobial misuse was recognized as early as the 1940s, when Alexander Fleming remarked on penicillin's decreasing efficacy, because of its overuse.[2]

In 1966, the first systematic assessment of antibiotic use in the Winnipeg, Canada general hospital was published: Medical records were reviewed during two non-consecutive four-month periods (medicine, psychiatry, urology, gynecology and surgery, orthopedics, neurosurgery, ear, nose and throat, and ophthalmology). Information was coded on punched cards using 78 columns.[3] Others in 1968 estimated that 50% of antimicrobial use was either unnecessary or inappropriate [4] This figure is likely the lower end of the estimate, and continues to be referenced as of 2015.

In the 1970s the first clinical pharmacy services were established in North American hospitals. The first formal evaluation of antibiotic use in children regarding antibiotic choice, dose and necessity of treatment was undertaken at The Children's Hospital of Winnipeg. Researchers observed errors in therapy in 30% of medical orders and 63% of surgical orders.[5] The most frequent error was unnecessary treatment found in 13% of medical and 45% of surgical orders. The authors stated "Many find it difficult to accept that there are standards against which therapy may be judged."

In the 1980s the antibiotic class of cephalosporins was introduced, further increasing bacterial resistance. During this decade infection control programs began to be established in hospitals, which systematically recorded and investigated hospital-acquired infections. Evidence-based treatment guidelines and regulation of antibiotic use surfaced. Australian researchers published the first medical guideline outcomes research.

The term AMS was coined in 1996 by two internists at Emory University School of Medicine, John Gowan and Dale Gerding, a specialist on C. difficile. They suggested "...large-scale, well-controlled trials of antimicrobial use regulation employing sophisticated epidemiologic methods, molecular biological organism typing, and precise resistance mechanism analysis [...] to determine the best methods to prevent and control this problem [antimicrobial resistance] and ensure our optimal antimicrobial use stewardship" and that "...the long-term effects of antimicrobial selection, dosage, and duration of treatment on resistance development should be a part of every antimicrobial treatment decision."[6]

In 1997, SHEA and the Infectious Diseases Society of America published guidelines to prevent antimicrobial resistance arguing that "…appropriate antimicrobial stewardship, that includes optimal selection, dose, and duration of treatment, as well as control of antibiotic use, will prevent or slow the emergence of resistance among microorganisms." [7]

Ten years later, in 2007, bacterial, antiviral and antifungal resistance had risen to such a degree that the CDC rang the alarm . The same year, IDSA and SHEA published guidelines for developing an AMS program.[8] Also in 2007, the first pediatric publication used the term AMS.[9]

A survey of pediatric infectious disease consultants in 2008 by the Emerging Infectious Disease Network revealed that only 45 (33%) respondents had an AMS program, mostly from before 2000, and another 25 (18%) planned an ASP (data unpublished).

In 2012, the SHEA, IDSA and PIDS published a joint policy statement on AMS.[10]

The CDC's NHSN has been monitoring antimicrobial use and resistance in hospitals that volunteer to provide data.[11]

In 2014, the CDC recommended, that all US hospitals have an antibiotic stewardship program.[12]

Benefits

Decreasing use of antimicrobials has the following proven benefits:

  1. improves patient outcomes, especially safety
  2. decreases adverse medication effects such as hypersensitivity reactions, kidney or heart damage (e.g.QT-prolongation).
  3. decreases Clostridium difficile-associated diarrhea
  4. decreases invasive candidiasis
  5. saves costs
  6. guards the patient's microbiome present in gastrointestinal, respiratory, urogenital tract, and on the skin.
  7. slows the increase in microbial resistance

Locations

AMS is needed wherever antimicrobials are prescribed in human medicine, namely in hospitals, outpatient clinics, and long term care institutions, including hospice.

Guidelines for prudent or judicious use in veterinary medicine have been developed by the Canadian Veterinary Medicine Association in 2008.[13] A particular problem is that veterinarians are both prescribers and dispensers. Regulators and the veterinary community in the European Union have been discussing the separation of these activities.[14]

Participants

Antimicrobial stewardship focuses on prescribers, be it physician, physician assistant, nurse practitioner, om the prescription and the microorganism, if any. At a hospital AMS is usually organized in the form of an AMS committee that meets monthly. The day-to-day work is done by a core group, usually an infectious disease physician, who may or may not serve in hospital epidemiology and infection control, or/ and a pharmacist, ideally but rarely aided by an information technologist. The entire committee may include physician representatives, who are top antimicrobial prescribers such as physicians in intensive care medicine, Hematology -Oncology, cystic fibrosis clinicians or hospitalists, a microbiologist, a quality improvement (QI) specialist, and a representative from hospital administration.

For an AMS program to be established the institution has to recognize its value. In the US it has become customary to present a business plan to the executive officers of the hospital administration.

Program Components

Thirteen Internet-Based Institutional ASP Resources in US Academic Medical Centers have been published [15] An AMS Program has the following tasks, in line with quality improvement theory:

1. Baseline assessment of antimicrobial use:

Since most US hospitals use electronic records, information technology resources are crucial to hone in on these questions. Commercial computer surveillance software programs for microbiology and antimicrobial administrations appear to outnumber "homegrown" institutional programs as of 2015, and include, but are not limited to TREAT Steward, TheraDoc, Sentri7, and Vigilanz.[16] 2. Set goals of desirable antimicrobial use

3. Intervention on antimicrobial prescribing

4. Provide feedback, continuing education on antimicrobials and continued improvement on use.

Rapid diagnostic methods are considered part of the program by some as well. Case studies of countries that introduced AMS are available at[17]

Interventions

The day-to-day work of the core AMS members is to screen patients' medical records for some of the following questions, in order of importance:

If the answer is no, the team needs to effectively communicate a recommendation, which may be in person or in the medical record.

Further tasks are:

Outcomes to measure

Two pediatric infectious disease physicians have suggested to look at the following variables to judge the outcome of AMS interventions:[18]

When examining the relationship between an outcome and an intervention, the epidemiological method of time series analysis is preferred, because it accounts for the dependence between time points. A recent global stewardship survey identified barriers to the initiation, development and implementation of stewardship programmes internationally.[19]

Controversies

It can be difficult to decide if a clinical syndrome or a particular drug should be targeted for interventions and education. How to best modify prescriber behavior has been the subject of controversy and research. At issue is how feedback is presented to prescribers, individually, in aggregate, with or without peer comparisons, and whether to reward or punish. As long as the best quality metrics for an AMS program are unknown, a combination of antimicrobial consumption, antimicrobial resistance, and antimicrobial and drug resistant organism related mortality are used.[20]

See also

References

  1. Dellit TH; et al. (1 January 2007). "Guidelines for Developing an Institutional Program to Enhance Antimicrobial Stewardship". SHEA. Retrieved 9 November 2013.
  2. "Fleming, Alexander: The Penicillin Finder Assays its Future". The New York Times. 25 June 1945. p. 21.
  3. Ruedy, J. (1966). "A method of determining patterns of use of antibacterial drugs.". Can Med Assoc J. 95 (16): :807–12. PMID 5928520.
  4. Reimann; D’Ambola (1968). "Cost of antimicrobial drugs in a hospital.". JAMA 205: 537. doi:10.1001/jama.205.7.537. PMID 5695313.
  5. Schollenberg, E.; Albritton WL (1980). "Antibiotic misuse in a pediatric teaching hospital.". Can Med Assoc J. 122 (1): 49–52. PMID 7363195. Retrieved 7 March 2014.
  6. McGowan, JE Jr,; Gerding (August 1996). "Does antibiotic restriction prevent resistance?" Check |url= value (help). New Horizon 4 (3): 370–6. PMID 8856755.
  7. Shlaes, D; et al. (April 1997). "Guidelines for the prevention of antimicrobial resistance in hospitals." Check |url= value (help). Infect Control Hosp Epidemiol. 418: 275–91. PMID 9131374. Retrieved 7 March 2014.
  8. "Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship.". Clin Infect Dis 44: 159–177. 2007. doi:10.1086/510393. PMID 17173212.
  9. Patel, SJ; Larson EL; Kubin CJ; Saiman L (June 2007). "A review of antimicrobial control strategies in hospitalized and ambulatory pediatric populations" Check |url= value (help). Pediatr Infect Dis J 26 (6): 531–7. doi:10.1097/inf.0b013e3180593170. PMID 17529873. Retrieved 7 March 2014.
  10. Society for Healthcare Epidemiology of America; Infectious Diseases Society of America; Pediatric Infectious Diseases Society. (April 2012). "Policy statement on antimicrobial stewardship by the Society for Healthcare Epidemiology of America (SHEA), the Infectious Diseases Society of America (IDSA), and the Pediatric Infectious Diseases Society (PIDS).". Infect Ctrl Hosp Epidemiol. 334322-7: 322–7. doi:10.1086/665010. PMID 22418625.
  11. HICPAC (March 2013). "Updates on NHSN Monitoring of Antimicrobial Use and Resistance" (PDF). Retrieved 1 June 2014.
  12. Loria A. Pollack, Arjun Srinivasan (2014). "Core Elements of Hospital Antibiotic Stewardship Programs From the Centers for Disease Control and Prevention". Clin Infect Dis 59 (suppl 3): S97–S100. doi:10.1093/cid/ciu542. Retrieved 9 March 2015.
  13. CVMA (2008). "CVMA Prudent Use Guidelines 2008 for beef cattle, dairy cattle, poultry, and swine".
  14. "Federation of Veterinarians of Europe (FVE) concerned about separating antimicrobial prescribing and supply". Vet Rec. 15 (171(24)): 609. December 2012. doi:10.1136/vr.e8348.
  15. Timothy P. Gauthier, Evan Lantz, Alexander Heyliger, Sarah M. Francis, Laura Smith (2014). "Internet-Based Institutional Antimicrobial Stewardship Program Resources in Leading US Academic Medical Centers". Clinical Infectious Diseases 58 (3): 445–446. doi:10.1093/cid/cit705.
  16. Jason G. Newland; Jeffrey S. Gerber; Scott J. Weissman; Samir S. Shah; Chelsea Turgeon; Erin B. Hedican; Cary Thurm; Matt Hall; Joshua Courter; Thomas V. Brogan; Holly Maples; Brian R. Lee; Adam L. Hersh (March 2014). "Prevalence and Characteristics of Antimicrobial Stewardship Programs at Freestanding Children’s Hospitals in the United States.". Infection Control and Hospital Epidemiology 35 (3): 265–271. doi:10.1086/675277. PMID 24521592.
  17. Be SMART with Resistance, Biomerieux, Intern. Newsletter October 2013, 8pp
  18. Newland, Jason; Adam Hersh (2010). "Purpose and design of antimicrobial stewardship programs in pediatrics.". Pediatr Infect Dis J 29: 862–863. doi:10.1097/INF.0b013e3181ef2507. PMID 20720473.
  19. Howard P. et al., ESCMID Study Group for Antimicrobial Policies (ESGAP) & ISC. Group on Antimicrobial Stewardship ECCMID 2013, Berlin Presentation Nr. 24
  20. Morris, Brener S, S (2012). "Use of a structured panel process to define quality metrics for antimicrobial stewardship programs.". Infect Ctrl Hosp Epidemiol 33: 500–6. doi:10.1086/665324. PMID 22476277. Retrieved 7 March 2014.

External links

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