Antimicrobial stewardship programs in health care systems

Abstract

Antimicrobial stewardship programs in hospitals seek to optimize antimicrobial prescribing in order to improve individual patient care as well as reduce hospital costs and slow the spread of antimicrobial resistance. With antimicrobial resistance on the rise worldwide and few new agents in development, antimicrobial stewardship programs are more important than ever in ensuring the continued efficacy of available antimicrobials. The design of antimicrobial management programs should be based on the best current understanding of the relationship between antimicrobial use and resistance. Such programs should be administered by multidisciplinary teams composed of infectious diseases physicians, clinical pharmacists, clinical microbiologists, and infection control practitioners and should be actively supported by hospital administrators. Strategies for changing antimicrobial prescribing behavior include education of prescribers regarding proper antimicrobial usage, creation of an antimicrobial formulary with restricted prescribing of targeted agents, and review of antimicrobial prescribing with feedback to prescribers. Clinical computer systems can aid in the implementation of each of these strategies, especially as expert systems able to provide patient-specific data and suggestions at the point of care. Antibiotic rotation strategies control the prescribing process by scheduled changes of antimicrobial classes used for empirical therapy. When instituting an antimicrobial stewardship program, a hospital should tailor its choice of strategies to its needs and available resources.

Figures

FIG. 1.

Segmented regression analysis of interrupted time series data. (Adapted from reference 3a with permission of the publisher.)

FIG. 2.

Illustration of possibility of publication bias in studies of antimicrobial use and resistance. Linear least-squares regression of changes in fluoroquinolone use on the changes in proportion of fluoroquinolone-resistant P. aeruginosa in 19 hospitals between 2000 and 2003 (authors' unpublished data). Eight hospitals decreased fluoroquinolone (FQ) use, but in only one hospital was there an important decline in resistance (circled marker). Likewise, most hospitals increased quinolone use but only one had a marked increase in rates of resistance (squared marker). These outlying observations may be more likely to be published and would exaggerate the modest relationship between changes in use and resistance noted across all hospitals. DDD/1000PD, defined daily doses per 1,000 patient-days.

FIG. 3.

Antimicrobial prescribing process and antimicrobial stewardship strategies.