The Importance of an Antimicrobial Stewardship Program

Antimicrobial order forms can be used to help monitor the implementation of formulated institutional clinical practice pathways. However, the authors feel that documenting this indication in the clinician notes may be adequate and save time for everyone involved; additionally, reviewing combination therapy, which if avoided, may prevent the emergence of resistance. Although combination therapy is needed in certain clinical diagnostic situations, careful consideration of its use is essential.

Using the appropriate antimicrobial dose based on the specific pathogen, patient characteristic, source of infection, along with the pharmacokinetic and pharmacodynamics should be reviewed to prevent antimicrobial overuse.Streamlining or de-escalation of therapy by using a narrower spectrum agent, based on culture and sensitivity results, prevents duplicative therapy with a patient when double coverage is not indicated or intended. Another goal is the discontinuation of therapy based on negative culture results and lack of supporting clinical signs and symptoms of infection. Dose optimization and adjustment should also be reviewed. Using the appropriate antimicrobial dose based on the specific pathogen, patient characteristic, source of infection, along with the pharmacokinetic and pharmacodynamics should be reviewed to prevent antimicrobial overuse and subsequent potentially avoidable adverse effects.

Parenteral to oral conversion from IV to oral administration (IV to oral) antimicrobials must be considered when the patient is clinically and hemodynamically stable, thus limiting the length of hospital stays and health care costs. However, it is important to keep in mind pharmacokinetic studies examining the bioavailability of antibiotics are usually conducted with healthy volunteers. Therefore, when treating patients who are elderly, on multiple medications, or severely ill, proper usage of these antibiotics is required. Also, having antibiotics with excellent bioavailability does not necessarily mean switching from IV to oral routes when treating serious infections such as bacteremia. Special consideration should be given when changing the route of administration. In addition, approval—or at least notification by the treating physician or ID specialist—should be included in the absence of an institutional policy, allowing for automatic IV to oral conversion.

The ASP Team

The participation of specific clinicians has been suggested as key to having a successful ASP team.¹² Members should include an ID physician (director) who serves as the lead physician and supervises the overall function of the ASP, makes recommendations to the ASP team, and contributes to the educational activities. A clinical ID pharmacist (codirector) provides suggestions to clinicians on preferred first-line antimicrobials and reviews medication orders for antimicrobials and resistance patterns, microbiological data, patient data, and clinical information. The codirector also tracks any ASP-related data and submits monitoring reports on a regular basis.

If accessible, an IC professional should participate, implementing and monitoring prevention strategies that decrease health care-associated infections. These infections play a significant role in reducing MDROs and decreasing the use of antibiotics. Additionally, the IC professional can assist in the early identification of patients with MDROs, aid patient placement on transmission-based precautions, and flag a patient in the medical record for hightened awareness. Also, IC professionals promote hand hygiene, standard precautions, and contribute to infection prevention strategies, such as hospital bundle practices, to prevent catheter-associated bloodstream infections and ventilator-associated pneumonias, among others.

If possible, a microbiologist who can prepare culture and susceptibility data to optimize antimicrobial management and conduct timely documentation of microbial pathogens should be a member of the team. Microbiologists can report organism susceptibility, assist in the surveillance of specific organisms, and provide early identification of patients with MDROs that require transmission-based precautions. The microbiologist can perform a semiannual update of a local antibiogram while reporting antimicrobial susceptibility profiles. Based on the information gathered, microbiologists can provide new drug panels to the members of the ASP, who will decide which antibiotic panel will be used. Another possible member of the ASP team is a program analyst who provides data retrieval, performs data analysis, and delivers necessary reports to the team.

It is the responsibility of medical staff to review and implement suggestions made by the ASP when appropriate. However, these suggestions are not considered a substitute for clinical decisions, and discretion is required when treating individual patients. The VHA, in response to the IDSA/SHEA published guidelines, chartered an antimicrobial stewardship task force in May 2011 with the sole purpose “To optimize the care of Veterans by developing, deploying and monitoring a national-level strategic plan for improvements in antimicrobial therapy management.”¹ In 2011, the Office of Inspector General in a combined assessment program summary report for management of MDROs in VHA facilities recommended that “the Under Secretary for Health, in conjunction with VISN and facility senior managers, ensures that facilities develop policies and programs that control and reduce antimicrobial agent use.”¹³