While the development of antibiotics has been one of the most prominent achievements in healthcare, there are at least two million people in the United States who become infected each year with antibiotic-resistant bacteria, and at minimum, 23,000 deaths resulting from these infections.
Because the use - or misuse - of antibiotics is the most important factor that causes worldwide antibiotic resistance, a concerted effort to better educate and steward antibiotic usage was initiated by national organizations, including the Centers for Disease Control (CDC)1 and the Infectious Diseases Society of America (IDSA).2 These organizations, along with others, developed guidelines based on clinical data and best practices to enhance antimicrobial stewardship and encourage appropriate antimicrobial use.
The bottom line of these efforts is simple: improve patient outcomes by reducing unnecessary morbidity and mortality caused by inappropriate antibiotic usage. A secondary goal is to reduce healthcare costs with a program that enhances appropriate antimicrobial use.
Optimized clinical outcomes can be achieved by following a few core guidelines, including the following:
Implementation of policies and interventions to improve antibiotic use (3)
Documenting and specifying the dosage, duration, and indication for all antibiotic courses improves information access and helps to ensure that antibiotic use is modified if necessary or even discontinued.
Develop and implement appropriate antimicrobial use policies that are facility-specific. While national guidelines are important, local conditions should not be ignored. There may be local susceptibilities and formulary options that physicians and pharmacists can use to optimize antibiotic selection for the local population.
Pharmacy-driven programs (4)
Institution of automatic changes from IV to oral antibiotic therapy, in appropriate circumstances and only for antibiotics that show good absorption (fluoroquinolones, linezolid, etc). This strategy, notes the CDC, improves patient safety by reducing the need for IV access, a frequent source of unintended infection.
Detection programs that can prevent antibiotic-related drug-use interactions; for example, interactions between some orally-administered fluoroquinolones and certain vitamins.
Prospective audit with intervention and feedback (5)
This strategy has been found to be effective in improving appropriate antimicrobial use. For example, this approach was used at a medium-sized community hospital, under the direction of a clinical pharmacist and infectious diseases physician. The result was a 22 percent decrease in the use of parenteral broad-spectrum antimicrobials, and a decrease in the rates of C. difficile infection and nosocomial infection caused by drug-resistant Enterobacteriaceae, compared with the pre-intervention period.
A robust surveillance system can help capture overall antibiotic usage and the use of specific antibiotics. It facilitates better antimicrobial stewardship through superior targeting of interventions, computerized tracking of antimicrobial resistance patterns, and the identification of nosocomial infections as well as adverse drug events. (6)
Integrating information technology such as electronic surveillance into the clinical environment will enable better decisions regarding appropriate antimicrobial use. Surveillance programs that can monitor antimicrobial agent selection by clinician and throughout the healthcare facility offer invaluable insight into key patterns of antibiotic use and emerging resistance profiles; such systems help highlight opportunities for educating clinicians on best practices for dosing and administration.
What strategies have helped your institution enhance appropriate antimicrobial use?
- Centers for Disease Control and Prevention. http://www.cdc.gov/
- Infectious Diseases Society of America. http://www.idsociety.org/Index.aspx
- Centers for Disease Control and Prevention. Core Elements of Hospital Antibiotic Stewardship Programs. 2014 http://www.cdc.gov/getsmart/healthcare/implementation/core-elements.html
- Dellit, Timothy H. et al. Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America Guidelines for Developing an Institutional Program to Enhance Antimicrobial Stewardship. CID 2007:44 January 15.