{"id":181,"date":"2019-10-07T20:50:42","date_gmt":"2019-10-07T15:20:42","guid":{"rendered":"https:\/\/medicineplexus.com\/?p=181"},"modified":"2019-10-07T20:50:42","modified_gmt":"2019-10-07T15:20:42","slug":"antimicrobial-stewardship","status":"publish","type":"post","link":"https:\/\/medicineplexus.com\/antimicrobial-stewardship\/","title":{"rendered":"Antimicrobial Stewardship"},"content":{"rendered":"\n<p><strong>Antimicrobial Stewardship<\/strong><\/p>\n\n\n\n<ul><li>Antimicrobial stewardship\nrefers to a set of coordinated strategies to improve the use of antimicrobial\nmedications with the goal of enhancing patient health outcomes, reducing\nresistance to antibiotics, and decreasing unnecessary costs.<\/li><\/ul>\n\n\n\n<p><strong>Objectives<\/strong><\/p>\n\n\n\n<ul><li>Maximum antimicrobial benefit<\/li><li>Avoid harm from adverse\nreactions and drug allergies<\/li><li>Improve patient outcomes<\/li><li>Decrease antimicrobial\nresistance<\/li><li>Decrease healthcare costs<\/li><li>Antimicrobial stewardship\nprograms <strong>in hospitals seek to optimize\nantimicrobial prescribing in order to improve individual patient care as well\nas reduce hospital costs and slow the spread of antimicrobial resistance.<\/strong> <\/li><li>With antimicrobial resistance\non the rise worldwide and <strong>few new agents\nin development, antimicrobial stewardship programs are more important than ever<\/strong>\nin ensuring the continued efficacy of available antimicrobials.&nbsp;<\/li><\/ul>\n\n\n\n<p><strong>Antimicrobial\nresistance (AMR):<\/strong><\/p>\n\n\n\n<ul><li>AMR threatens the effective\nprevention and treatment of <strong>an\never-increasing range of infections caused by bacteria, parasites, viruses, and\nfungi<\/strong><\/li><li><strong>an increasingly serious threat to global public health<\/strong> that requires action across all government sectors and society.<\/li><li>Without effective antibiotics,\nthe <strong>success of major surgery and cancer\nchemotherapy<\/strong> would be <strong>compromised.<\/strong><\/li><li>The <strong>cost of health care for patients with resistant infections is higher<\/strong>\nthan care for patients with non-resistant infections due to <strong>longer duration of illness, additional\ntests and use of more expensive drugs<\/strong>.<\/li><li>In 2016, 4,90,000 people\ndeveloped multi-drug resistant TB globally, and drug resistance is starting to complicate\nthe fight against HIV and malaria, as well.<\/li><li>Therefore, these programs are\nneeded to help clinicians to improve the quality of patient care and improve patient\nsafety through increased infection cure rates, reduced treatment failures, and\nincreased frequency of correct prescribing for therapy and prophylaxis.<\/li><\/ul>\n\n\n\n<p><strong>What\nconstitutes an Antibiotic Stewardship Program (ASP)?<\/strong><\/p>\n\n\n\n<ul><li>usually involves pharmacists,\nphysicians, and other healthcare providers. <\/li><li>The Infectious Diseases Society\nof America\/Society for Healthcare Epidemiology of America (IDSA\/SHEA)\nGuidelines for Antimicrobial Stewardship were published in 2007. <\/li><li>According to these guidelines,\nan <strong>institutional antimicrobial\nstewardship program should include an <\/strong><ul><li><strong>infectious disease trained physician<\/strong> and\n<\/li><\/ul><ul><li><strong>an infectious disease trained pharmacist<\/strong>\nas core members, with the <strong>inclusion of a\n<\/strong><\/li><\/ul><ul><li><strong>clinical microbiologist,<\/strong><\/li><\/ul><ul><li><strong>an infection control practitioner, <\/strong><\/li><\/ul><ul><li><strong>an information systems expert and <\/strong><\/li><\/ul><ul><li><strong>a hospital epidemiologist<\/strong> considered\noptimal.<\/li><\/ul><\/li><\/ul>\n\n\n\n<p><strong>The\nrole of individuals in ASP:<\/strong><\/p>\n\n\n\n<p><strong>1.\nInfectious Disease Physician<\/strong><\/p>\n\n\n\n<ul><li>Helps in the <strong>design, implementation and proper\nfunctioning of the program.<\/strong><\/li><li>ensures that therapeutic\nguidelines, antimicrobial restriction policies, or other measures are based on\nthe best evidence and practice and will not put patients at risk.<\/li><\/ul>\n\n\n\n<p><strong>2.\nClinical and Hospital pharmacists<\/strong><\/p>\n\n\n\n<ul><li>act as the effector arms for\nantimicrobial stewardship programs because of their role in processing\nmedication orders and their familiarity with the hospital formulary. <\/li><li>Due to this role, <strong>they may note when restricted\nantimicrobials are ordered and notify the prescriber that authorization is\nrequired<\/strong>.<\/li><li>They <strong>may also flag orders for review by infectious disease specialists,<\/strong>\nin addition to their usual role in assuring proper dosing and safety.<\/li><li>However, the broad\nresponsibilities of these pharmacists <strong>generally\ndo not allow adequate time for a comprehensive review of antimicrobial therapy.<\/strong>\n<\/li><li>In addition, these pharmacists <strong>may not have adequate training in\ninfectious diseases<\/strong> to feel comfortable providing recommendations for\ncomplex cases. <\/li><li>Thus, <strong>having a clinical pharmacist with specialized training in infectious\ndiseases<\/strong> dedicated full or part-time to the administration of the\nantimicrobial stewardship program is increasingly common.<\/li><\/ul>\n\n\n\n<p><strong>3.\nClinical Microbiologists: <\/strong><\/p>\n\n\n\n<ul><li>The clinical microbiology\nlaboratory is a key component in the function of antimicrobial stewardship\nprograms. <\/li><li><strong>provide Summary data on antimicrobial resistance rates<\/strong> that allow the antimicrobial stewardship team to d<strong>etermine the current burden of\nantimicrobial resistance in the hospital, facilitating decisions <\/strong>as to\nwhich antimicrobials to target for restriction or review.<\/li><li>They prepare antibiograms\nspecific to certain patient care areas, especially intensive care units, that\nallow identification of local problems and focused antimicrobial stewardship\nand infection control efforts. <\/li><li>Also, having <strong>resistance data available on a monthly or\nquarterly basis allows closer tracking of trends and facilitates well-designed\nstudies of interventions<\/strong><\/li><\/ul>\n\n\n\n<p><strong>4.\nInfection control staff and Hospital Epidemiologists:<\/strong><\/p>\n\n\n\n<ul><li>Infection control staff gather\nhighly detailed data on nosocomial infections which may assist in the antimicrobial\nstewardship team\u2019s evaluation of the outcomes of their strategies.<\/li><li>Hospital epidemiologists have\nthe expertise in surveillance and study design to lend to efforts studying the effect\nof antimicrobial stewardship measures. <\/li><li>In turn, antimicrobial\nstewardship programs may be able to assist in efforts to control outbreaks by\nfocused monitoring and\/or restriction of antimicrobials in the targeted units.<\/li><\/ul>\n\n\n\n<p><strong>5.\nHospital Administrators<\/strong><\/p>\n\n\n\n<ul><li>Program funding, institutional\npolicy, and physician autonomy are core issues in the development of antimicrobial\nstewardship programs that must be addressed by hospital administration. <\/li><li>Without adequate support from hospital\nleadership, program funding will be inadequate or inconsistent since the\nprograms do not generate revenue (although they may result in significant cost\nsavings). <\/li><\/ul>\n\n\n\n<p><strong>6.\nPharmacologists:<\/strong> <\/p>\n\n\n\n<ul><li>Pharmacologists need to be\nactively involved with microbiologists, infectious disease physicians, and\nothers, informing an antimicrobial policy within the hospital. <\/li><li>Pharmacologists could also use their\nknowledge in activities such as prescription audits, feedback, and monitoring\nantimicrobial use throughout the hospital. <\/li><li>Another area would be in\ninterpreting minimum inhibitory concentrations values when difficult treatment\ndecisions have to be made due to AMR.<\/li><\/ul>\n\n\n\n<p><strong>Types\nof ASP interventions:<\/strong><\/p>\n\n\n\n<p>Antimicrobial stewardship programs may be\ngenerally classified according to the strategy by which they seek to affect\nantimicrobial use. However, as noted, many programs use a combination of such\nstrategies.<\/p>\n\n\n\n<p><strong>1.\nEducation and Guideline Implementation Strategies:<\/strong><\/p>\n\n\n\n<ul><li>To counter perceived conflicts\nin knowledge and practice, institutions may attempt to provide guidelines for antimicrobial\nuse and educate clinicians regarding preferred antimicrobial therapy. <\/li><li>This strategy attempts to influence\nproviders\u2019 prescribing during their evaluation of the patient and the selection\nof antimicrobial therapy.<\/li><li>The approaches taken vary\nwidely, from posting copies of national guidelines on the institution\u2019s website\nto the formulation of consensus local guidelines with academic detailing and\nprescriber feedback. <\/li><li>Academic detailing refers to\none-on-one educational sessions between an academic clinician-educator (usually\na physician or pharmacist) and the clinician targeted for education. <\/li><li>Prescriber feedback consists of\nproviding data to clinicians regarding their prescribing habits, with comparisons\nto expected norms (e.g., guidelines) or to other prescribers in the same\npractice area.<\/li><li>Although there is no shortage\nof evidence-based practice guidelines regarding antimicrobial use, including those\naddressing the problem of antimicrobial resistance, the mere publication of\nthese guidelines is insufficient to significantly impact antimicrobial\nprescribing patterns. <\/li><li>Adaptation of national\nguidelines to local circumstances, collaboration with hospital specialists,\nbroad dissemination of guidelines in easily accessible forms (print and\/or\nelectronic), and active educational methods such as academic detailing\n(targeted to the most influential clinicians first), are required to increase\nthe chances of the adoption of recommendations in clinical practice.<\/li><\/ul>\n\n\n\n<p><strong>2.\nFormulary and Restriction Strategies:<\/strong><\/p>\n\n\n\n<ul><li>Because of poor compliance with\nguidelines for antimicrobial usage, external control over clinicians\u2019 prescribing\nof these drugs may be implemented.<\/li><\/ul>\n\n\n\n<p>The different types of strategies used are:<\/p>\n\n\n\n<p><strong>Criterion\nmonitored strategies<\/strong> \u2013 <\/p>\n\n\n\n<ul><li>In this, only selected\nantimicrobial agents are freely dispensed by the pharmacy. <\/li><li>Other agents may only be\navailable if certain criteria for use are met.<\/li><\/ul>\n\n\n\n<p><strong>Prior-authorization\nstrategies<\/strong>&#8211; <\/p>\n\n\n\n<ul><li>In this, the antibiotics are\ndispensed if approval for use is obtained from a specialist in infectious\ndiseases.<\/li><\/ul>\n\n\n\n<p><strong>Closed-formulary\nstrategies<\/strong> \u2013 <\/p>\n\n\n\n<ul><li>the antibiotics may not be available\nat all.<\/li><\/ul>\n\n\n\n<p><strong>3.\nReview and Feedback Strategies:<\/strong><\/p>\n\n\n\n<ul><li>To optimize the use of\nnon-restricted antimicrobials, or to manage the use of targeted antimicrobials\nin institutions where restriction strategies are not in place, programs built\naround antimicrobial review and feedback may be instituted. <\/li><li>Such a program involves the\nretrospective (hours to days) review of antimicrobial orders; if an order\nappears to be inappropriate, a member of the antimicrobial management team\ncontacts the prescriber in an effort to optimize therapy.<\/li><\/ul>\n\n\n\n<p><strong>4.\nComputer-Assisted Strategies:<\/strong><\/p>\n\n\n\n<ul><li>The increasing computerization\nof the hospital environment offers new opportunities for programs to optimize\nantimicrobial use. <\/li><li>These opportunities have\nprimarily been associated with the implementation <strong>of computerized physician order-entry systems in hospitals.<\/strong> <\/li><li><strong>The order-entry encounter can be designed to facilitate each of the\nantimicrobial stewardship strategies above. <\/strong><\/li><li>Educational strategies may be\nas simple as a <strong>link to the institution\u2019s\nguidelines for therapy<\/strong>, or as <strong>sophisticated\nas computerized expert systems that integrate patient-specific laboratory and\nmicrobiology data in devising a suggested therapeutic regimen<\/strong>. <\/li><li>If a prescriber enters an order\nfor a restricted agent, a list of formulary alternatives can be suggested,\nalong with the pager number needed to obtain authorization. <\/li><li>When an agent targeted for\nreview is ordered, the data can be forwarded in real-time or entered into a\nqueue for later review by antimicrobial stewardship personnel.<\/li><\/ul>\n\n\n\n<p><strong>5.\nAntibiotic Cycling Strategies<\/strong><\/p>\n\n\n\n<ul><li>It is a <strong>strategy of rotating antimicrobials that might be effective in slowing\nthe emergence of resistance to any one agent.<\/strong> <\/li><li>It involves scheduled rotation\nof antimicrobials in order to minimize the emergence of bacterial resistance. <\/li><li><strong>These programs typically target gram-negative resistance (the cycled\nantimicrobials are those primarily active against gram-negative organisms) and\nare generally limited to the intensive care unit setting.<\/strong><\/li><\/ul>\n\n\n\n<p><strong>Outcome\nMeasurements in ASP<\/strong><\/p>\n\n\n\n<p>varies widely, depending on program goals,\nstudy design, study duration, and measurement capabilities.<\/p>\n\n\n\n<p>Common outcome variables related to\nantimicrobial usage include:<\/p>\n\n\n\n<ul><li>The change in antimicrobial\nusage is the most common outcome measured in studies of stewardship programs. <\/li><li>Measurement of antimicrobial\nusage may be performed from patient charts or as aggregate antimicrobial use\n(e.g., in defined daily doses per 1,000 patient-days) from billing or\npurchasing data.<\/li><li>Quantity of total antimicrobial\nuse<\/li><li>Quantity of targeted\nantimicrobial use<\/li><li>Duration of therapy<\/li><li>Percentage of oral versus\nintravenous drug administration.<\/li><li>Antimicrobial drug\nexpenditures- these are often measured to demonstrate the cost savings (or at\nleast cost neutrality) associated with antimicrobial stewardship programs.<\/li><li>Clinical criteria are often\nincluded in studies to demonstrate that a change in antimicrobial usage does\nnot have a deleterious effect on patient outcomes. <\/li><li>Common clinical outcomes\ninclude all-cause mortality, infection-related mortality, duration of\nhospitalization, and rates of readmission. <\/li><li>Clinical cure or improvement\nmay also be measured, with or without a precise definition of the terms<\/li><li>Microbiologic outcomes include\nthe percentage of organisms resistant to a certain antimicrobial, percentage of\nmulti-drug-resistant organisms, or the number of infections due to specified\norganisms.<\/li><\/ul>\n\n\n\n<p><strong>The\navailable guidelines for ASP are:<\/strong><\/p>\n\n\n\n<p>1. IDSA: New Antimicrobial Stewardship\nGuideline 2016 &#8211; by Infectious Diseases Society of America.<\/p>\n\n\n\n<p>2. Antimicrobial Stewardship: Guidelines &#8211;\nby The Society for Healthcare Epidemiology of America (SHEA)<\/p>\n\n\n\n<p>3. Core Elements of Hospital Antibiotic\nStewardship Programs by Centres for Disease Control and Prevention<\/p>\n\n\n\n<p>4. Practice resources from the Association\nfor Professionals in Infectious Control and Epidemiology (APIC)<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Antimicrobial Stewardship Antimicrobial stewardship refers to a set of coordinated strategies to improve the use of antimicrobial medications with the goal of enhancing patient health outcomes, reducing resistance to antibiotics, and decreasing unnecessary costs. Objectives Maximum antimicrobial benefit Avoid harm from adverse reactions and drug allergies Improve patient outcomes Decrease antimicrobial resistance Decrease healthcare costs[&#8230;]\n","protected":false},"author":3,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_seopress_robots_primary_cat":"","_seopress_titles_title":"","_seopress_titles_desc":"","_seopress_robots_index":"","footnotes":""},"categories":[3],"tags":[],"_links":{"self":[{"href":"https:\/\/medicineplexus.com\/wp-json\/wp\/v2\/posts\/181"}],"collection":[{"href":"https:\/\/medicineplexus.com\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/medicineplexus.com\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/medicineplexus.com\/wp-json\/wp\/v2\/users\/3"}],"replies":[{"embeddable":true,"href":"https:\/\/medicineplexus.com\/wp-json\/wp\/v2\/comments?post=181"}],"version-history":[{"count":0,"href":"https:\/\/medicineplexus.com\/wp-json\/wp\/v2\/posts\/181\/revisions"}],"wp:attachment":[{"href":"https:\/\/medicineplexus.com\/wp-json\/wp\/v2\/media?parent=181"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/medicineplexus.com\/wp-json\/wp\/v2\/categories?post=181"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/medicineplexus.com\/wp-json\/wp\/v2\/tags?post=181"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}