“If we don’t address stewardship, we are doomed to failure.”
Ramanan Laxminarayan (Director of the Center for Disease Dynamics, Economics and Policy)
Antimicrobial stewardship is defined as a program which seeks to ensure that the right antibiotic is given to the right patient at the right time, with the right dose and the right route, causing the least harm to the patient and future patients. In realistic terms, it is a multidisciplinary approach that aims to ensure that patients benefit from the most effective antibiotic treatments, while limiting the side effects and costs of unnecessary treatments.
Successful antimicrobial stewardship programs require a continued and diligent interaction between all levels of healthcare providers, including physicians, infectious disease specialists, infection control practicioners, nursing staff, pharmacists, microbiologists, pathologists, lab directors and healthcare administrators.
The core elements of antimicrobial stewardship programs include:
- Implementation of national and international guidelines and clinical pathways for the diagnosis and treatment of infectious diseases
- Limiting the use of antibiotics where not needed or not indicated
- Delivering the most appropriate antibiotic, with the correct dose established according to the type and site of infection, patient’s age, weight and clinical situation
- Switching antibiotics from parenteral to oral form as soon as possible
- Timely conversion to the most narrow antibiotic spectrum according to the organism susceptibility
- Use of the shortest effective antibiotic course and discontinuation of antibiotic courses as soon as possible
The leading factor in the emergence of antibiotic resistance is the inappropriate use of antibiotics in both humans and animals. Available data highlight a correlation between the use of antibiotics and resistance rates in a given country.(54) Even though detailed and reliable data remain unavailable for many parts of the world, it is clear that antibiotic resistance is as much an issue for emerging nations as it is for the developed world. As populations are mixing through tourism and migration, various microbes with antibiotic resistance genes are spreading worldwide, implying the need for global coordinated efforts.(55)
The report entitled The State of the World’s Antibiotics 2015, published by the Center for Disease Dynamics, Economics & Policy (CDDEP), stated that incentives have focused on the development of new antibiotics, but insufficient attention has been paid to conserving the effectiveness of our existing antibiotic arsenal. Global antibiotic stewardship in the broadest sense should make it possible not only to conserve the current effectiveness of existing antibiotics, but even to reclaim some of the effectiveness that has been lost through bacterial mutations.
Report co-author and CDDEP Director Ramanan Laxminarayan believes that 80% of our global resources for controlling AMR should be focused on antimicrobial stewardship, and no more than 20% on drug development; because no matter how many new drugs come out, they will all generate resistant bacterial mutants if we continue to misuse them.
-> More on over-use and misuse of antibiotics
classificationIn 2017, new advice on which antibiotics to use for common infections and which to preserve for the most serious circumstances was among the additions to the WHO Model list of essential medicines. This list is used by many countries to increase access to medicines and guide decisions about which products they ensure are available for their populations. WHO experts grouped antibiotics used to treat 21 of the most common general infections into three categories: ACCESS, WATCH and RESERVE groups.
Healthcare providers have an essential role to play in the appropriate use of these drugs to contain the emerging antibiotic resistance problem. Rapid, high medical value diagnostics in conjunction with Antimicrobial Stewardship Programs can be used to support relevant decisions to withhold, de-escalate or stop antibiotic treatment earlier. Antimicrobial Stewardship Programs encourage rational prescribing of antibiotics and remind healthcare workers – and their patients – of the consequences of antibiotic over-use and misuse. In fact, we all need to change our views on antibiotics and reconsider them as shared non-renewable resources, which must be preserved.
While the optimal approach to effective antimicrobial stewardship remains elusive and may vary significantly between settings, a wide array of studies and reviews from diverse healthcare contexts have demonstrated the positive impact of stewardship programs on limiting antibiotic resistance.(62)
The U.S. Center for Infectious Disease Research and Policy offers information and educational resources on antimicrobial stewardship practice, research and policy.
State-of-the-art guidelines and information are essential for antimicrobial stewardship programs.
In 2016, the Infectious Diseases Society of America and the American Thoracic Society published new guidelines recommending a shorter duration of antibiotic treatment in adults with two common hospital-acquired infections: ventilator-associated pneumonia and hospital-acquired pneumonia. Shortening the course of antibiotic treatment reduces the potential for antibiotic resistance, while maintaining the benefit of the treatment. The new guidelines also recommend that hospitals use antibiograms to determine the most appropriate treatment.
A WHO expert panel has updated the list of antibiotics considered most important to human medicine(85). Fluoroquinolones, macrolides, third-generation cephalosporins, glycopeptides and carbapenems are identified as the highest priority antibiotics to be preserved. The list is intended to support stewardship efforts, particularly in the context of animal farming.
- Establish a clear aim/vision that is shared by all stakeholders and that conveys a sense of urgency. Stewardship should be a patient safety priority.
- Seek management support, accountability and secure funding.
- Assemble a strong coalition including a multi-professional antimicrobial stewardship team with an influential clinical leader.
- Establish effective communication structures within your hospital.
- Start with core evidence-based stewardship interventions depending on local needs, geography and resources and set up measurement strategies to demonstrate their impact.
- Ensure that all healthcare staff are aware of the importance of hospital-based antimicrobial stewardship. Empower them to act and to support others using a range of effective advocacy tools.
- Ensure early or short-term wins and then consolidate success/gains while progressing with further change and innovation.
Source: “Practical Guide to Antimicrobial Stewardship in Hospitals”(63)
Clostridium difficile: a deadly side-effect
When a person takes antibiotics, the “good bacteria” present in our microbiome that offer some protection against infection can be destroyed. At that time, an individual in contact with Clostridium difficile (otherwise known as “C. difficile” or “C. diff”) can develop a potentially deadly form of diarrhea called “C. difficile infection” (CDI). The people receiving antibiotics who are most at risk include older adults in both acute care hospitals and long-term care facilities, patients in critical care units and individuals with an impaired immune system. In 2011, half a million Americans acquired CDI and the US Centers for Disease Control (CDC) estimated that it killed 15,000 of them.(67)
bioMérieux solutions for the management of C. difficile