The Importance of an Antimicrobial Stewardship Program
Rosa and colleagues discussed adherence to an ASP and the effects on mortality in hospitalized cancer patients with febrile neutropenia (FN).8 A prospective cohort study was performed in a single facility over a 2-year period. Patients admitted with cancer and FN were followed for 28 days. The mortality rates of those treated with ASP protocol antibiotics were compared with those treated with other antibiotic regimens. One hundred sixty-nine patients with 307 episodes of FN were included. The rate of adherence to ASP recommendations was 53% with the mortality of this cohort 9.4% (29 patients).8
Older patients were more likely to be treated according to ASP recommendations, whereas patients with comorbidities were not treated with ASP guidelines, Rosa and colleagues noted.8 No explanation was given, but statistical testing did uphold these findings, ensuring that the results were correctly interpreted. The 28-day mortality during FN was related to several factors, including nonadherence with ASP recommendations (P = .001) relapsing diseases stages (P = .001), and time to antibiotic start therapy > 1 hour (P = .001). Adherence to the ASP was independently associated with a higher survival rate (P = .03), whereas mortality was attributable to infection in all 29 patients who died.
Nowak and colleagues reviewed the clinical and economic benefits of an ASP using a pre- and postanalysis of potential patients who might benefit from recommendations of the ASP.9 Subjects included adult inpatients with pneumonia or abdominal sepsis. Recommendations from ASP that were followed decreased expenditures by 9.75% during the first year and remained stable in the following years. The cumulative cost savings was about $1.7 million. Rates of nosocomial infections decreased, and pre- and postcomparison of survival and lengths of stay for patients with pneumonia (n = 2,186) or abdominal sepsis (n = 225) revealed no significant differences. Investigators argued that this finding may have been due to the hospital’s initiation of other concurrent IC programs.
Doron and colleagues conducted a survey identifying characteristics of ASP practices and factors associated with the presence of an ASP.10 Surveys were received from 48 states (North and South Dakota were not included) and Puerto Rico. Surveys were received from 406 providers, and 96.4% identified some form of ASP. Barriers to implementation included staffing constraints (69.4%) and insufficient funding (0.6%).10
About 38% of the responses stated ASP was being used for adults and pediatric patients, whereas 58.8% were used for adults only.10 The ASP teams were composed of a variety of providers, including infectious disease (ID) physicians (70.7%), IC professionals (51.1%), and clinical microbiologists (38.6%). Additional barriers to implementing an ASP were found as insufficient medical staff buy-in (32.8%), not high on the priority list (22.2%), and too many other things to consider or deal with at the time (42.8%). Interestingly, 41.1% of the subjects in facilities without an ASP responded that providers agree with limiting the use of antimicrobials compared with 66.9% of subjects in hospitals with an ASP. Factors linked to having an ASP included having an ID consultation service, an ID fellowship program, an ID pharmacist, larger hospitals, annual admissions > 10,000, having a published antibiogram, and being a teaching hospital.
Establishment of an ASP
The Infectious Diseases Society of America (IDSA) and the Society for Healthcare Epidemiology of America (SHEA) issued guidelines in 2007 for developing an institutional ASP to enhance antimicrobial stewardship and help prevent antimicrobial resistance in hospitals.11 The ASP may vary among facilities based on available resources.
When developing an ASP, 2 core strategies are necessary. The core measures are proactive and are usually conducted by an ID clinical pharmacist assigned to the ASP in collaboration with the ID physician. These strategies are not mutually exclusive and include a prospective audit with interventions provided to the clinicians, resulting in decreased inappropriate use of antimicrobials or a formulary restriction and preauthorization to help reduce antimicrobial usage and related cost.
Supplemental elements may be considered and prioritized as to the core antimicrobial stewardship strategies based on local practice pattern and resources.11 Factors to consider include education, which is considered to be an essential element of the ASP. Although education is important, it alone is only somewhat effective in changing clinicians’ prescribing practices. Guidelines and clinical pathways are elements set forth in institutional management protocols for common and potentially serious infections such as intravascular catheter-related infections, hospital- and community-acquired pneumonia, bloodstream infections, and complicated urinary tract infections among other types.
Another consideration is antimicrobial cycling. This process refers to the specific schedule of alternating specific antimicrobials or antimicrobial classes to prevent or reverse the development of antimicrobial resistance. Insufficient data on antimicrobial cycling currently exist to affect major changes in practice. This element, however, could be implemented in certain institutions if needed based on the reported bacterial resistance pattern.
