Implementing an Antimicrobial Stewardship Program

➡️Rationale

With rates of AMR increasing worldwide, and very few new antibiotics being developed, existing antibiotics are becoming a limited resource. It is therefore essential that antibiotics only be prescribed – and that last-resort antibiotics (AWaRe RESERVE group) be reserved – for patients who truly need them. Hence, AMS and its defined set of actions for optimizing antibiotic use are of paramount importance

➡️Program structure & governance

An AMS committee in the health-care facility should provide leadership and overall coordination of the AMS programme. The AMS committee can be a stand-alone committee or be integrated into an existing structure, such as the infection control, patient safety or drug and therapeutics committee with clear terms of reference.

Stewardship programs are greatly enhanced by strong support from the following groups:

●      Infection prevention and control: It is often the same people involved in issues related to IPC and AMS both at the facility level and the national (state/regional) level. This is because IPC and AMS are two sides of the same coin when it comes to development and spread of AMR, optimizing antibiotic use and providing quality health care. IPC team role involve ensuring that effective strategies to reduce the spread of infections and AMR are integrated into patient care.

●      Clinicians: It is vital that all clinicians are fully engaged in and supportive of efforts to improve antibiotic use. Hospitalists are especially important to engage because they are one of the largest prescribers of antibiotics in hospitals. They also often have experience with quality improvement work.

●      Department or program heads: Support from clinical department heads, as well as the director of pharmacy, is especially important in embedding stewardship activities in daily workflow.

●      Pharmacy and therapeutics committee: Can play a key role in helping to develop and implement policies that will improve antibiotic use (e.g. incorporating stewardship into order sets and clinical pathways).

Some hospitals have created a multidisciplinary stewardship subcommittee of the Pharmacy and Therapeutics Committee. Infection preventionists and hospital epidemiologists can assist with educating staff and with analyzing and reporting data on antibiotic resistance and C. difficile infection trends. 

●      Quality improvement, patient safety and regulatory staff: can help advocate for adequate resources and integrate stewardship interventions into other quality improvement efforts, especially sepsis management. They might also be able to support implementation and outcome assessments.

●      Microbiology laboratory staff can:

−        Guide the proper use of tests and the flow of results as part of "diagnostic stewardship".

−        Help optimize empiric antibiotic prescribing by creating and interpreting a facility cumulative antibiotic resistance report or antibiogram.

−        Laboratory and stewardship personnel can work collaboratively to present data from lab reports in a way that supports optimal antibiotic use and is consistent with hospital guidelines.

−        Guide discussions on the potential implementation of rapid diagnostic tests and new antibacterial susceptibility test interpretive criteria (e.g., antibiotic breakpoints) that might impact antibiotic use. Microbiology labs and stewardship programs can work together to optimize the use of such tests and the communication of results.

−        Collaborate with stewardship program personnel to develop guidance for clinicians when changes in laboratory testing practices might impact clinical decision making. Hospitals where microbiology services are contracted to an external organization should ensure that information is available to inform stewardship efforts.

●      Information technology staff are critical to integrating stewardship protocols into existing workflow. Some examples include:

−        Embedding relevant information and protocols at the point of care (e.g., order sets, access to facility-specific guidelines).

−        Implementing clinical decision support for antibiotic use and creating prompts for action to review antibiotics in key situations.

−        Facilitating and maintaining reporting.

➡️Core AMS interventions

●       Improve awareness and understanding of AMR through effective communication, education and training.

●       Strengthen the knowledge and evidence base through surveillance and research.

●       Reduce the incidence of infection through effective sanitation, hygiene and infection prevention measures.

●       Optimize the use of antimicrobial medicines in human and animal health.

➡️Prescribing & optimization practices

Early IV-to-PO switch: Hospitalized patients initially on intravenous antibiotics can be safely switched to an oral equivalent within the third day of admission once clinical stability is established. This conversion has many advantages as fewer complications, less healthcare costs and earlier hospital discharge.

There are so many benefits of reducing unnecessary IV antibiotics, including better patient care, freeing up nursing time, reducing waste, and saving money. Patients taking oral antibiotics are less likely to experience line-related infections, to miss any doses and to suffer adverse effects from medications.

➡️De-escalation of empiric antibiotic therapy is a strategy in antimicrobial stewardship where treatment is modified from a broad-spectrum antibiotic to a narrower-spectrum one, or stopped altogether, based on culture results and the patient's clinical response. This approach is used to match the antibiotic therapy more precisely to the specific pathogen, reduce the overall use of antibiotics, and help prevent the development of antibiotic resistance and other complications.

➡️Infection control practitioners can participate in AMS through:

·       Advising on appropriate governance structures for AMS.

·       A patient-centric approach to managing risk.

·       Making current endorsed therapeutic guidelines on antimicrobial prescribing readily available.

·       Participating in multidisciplinary antimicrobial stewardship committees that include infectious diseases physicians, general practitioners, pharmacists, microbiologists, and nurses.

·       Educating healthcare workers on infection prevention and control strategies to minimise risk and transmission of antimicrobial resistance, including safe and appropriate antibiotic use.

·       Advising healthcare workers on appropriate specimen collection procedures, different types of microbes and infections, and local resistance patterns.

·       Undertaking surveillance of antimicrobial-resistant organisms, healthcare- associated infections, and in some circumstances, surveillance of antimicrobial usage and appropriateness.

·       Reporting and providing feedback to teams on surveillance data

➡️Microbiology and surveillance enablers: Clinical microbiology laboratories are key to AMS programs, providing specimen collection and testing, rapid diagnostics, susceptibility testing, and production of antibiograms and education activities.

·       Antibiograms can provide an overview of the emergence of antibiotic resistance in particular settings over time.

·       Combination antibiograms may be particularly useful in managing infections due to multidrug-resistant organisms.

·       Cumulative antibiograms can guide empirical therapy and be used as an important teaching tool for enhancing clinician compliance.

Surveillance enablers in AMS programs are the resources, structures, and processes necessary to successfully monitor and optimize antimicrobial use, combat AMR, and protect public health. 

Key rationales for enablers include improving clinical outcomes by identifying resistance patterns, ensuring effective treatment, guiding appropriate antimicrobial selection, and ultimately reducing the harms of AMR and preserving the effectiveness of antimicrobials. Enablers, such as IT resources and leadership support, provide the foundation for effective surveillance, while their absence creates challenges that impede AMS program success.