Antimicrobial stewardship is a dedicated coordinated program designed to improve antibiotic use while optimizing treatment of infections and reducing adverse events associated with antibiotic use. Antimicrobial stewardship can help improve patient safety, reduce treatment failures, ensure correct prescribing of antibiotics, and reduce antibiotic resistance. Furthermore, antimicrobial stewardship can help save hospitals and post-acute centers significant amounts of money.
Unfortunately, there is no single template for a program to optimize antibiotic prescribing in hospitals. The variability in the size of the hospitals and the types of care among the hospitals in the United States require flexibility in their implementation. However, there are core elements outlined by the Centers for Disease Control and Prevention (CDC) for hospitals to utilize, which includes leadership support, accountability, antimicrobial expertise, implementing at least one recommended action such as evaluation of ongoing treatment, tracking and reporting of antimicrobial use and resistance patterns, and educating clinicians about optimal prescribing1.
When did antimicrobial stewardship start?
Historically, the term “antimicrobial stewardship” was mostly used in the narrow context of programs within individual hospitals. During the 1990s and 2000s, programs were developed and implemented in many countries including the United States2. In 1988, the Infectious Diseases Society of America (IDSA) published guidelines in order to improve antimicrobial use in hospitals then jointly in 1997 with the Society for Healthcare Epidemiology of America (SHEA) for the prevention of antimicrobial resistance in hospitals3.
How else has antimicrobial stewardship evolved?
In 2006, the CDC issued a guideline called “Management of Multi-Drug Resistant Organisms in Health Care Settings” which instructed facilities to closely monitor antimicrobial use1. In 2007, the IDSA and SHEA developed guidelines to develop effective antimicrobial stewardship programs. These guidelines stated core members of the antimicrobial stewardship team should include an infectious disease physician and a clinical pharmacist with infectious diseases training. Also, the team should include a clinical microbiologist, an information specialist, an infection control professional, and a hospital epidemiologist.
Furthermore, there were not specific strategies established due to the lack of randomized controlled trials but the IDSA stated the antimicrobial stewardship program should include active monitoring of resistance, fostering of appropriate antimicrobial use, and collaboration with an effective infection control program to minimize secondary spread of resistance3.
In 2009, the CDC launched its first educational effort to promote improved use of antibiotics in acute care hospitals. In 2013, the CDC highlighted the need to improve antibiotic use as one of four key strategies to help combat antibiotic resistance in the United States. In 2014, the CDC recommended that all acute care hospitals implement Antibiotic Stewardship Programs1. The Joint Commission, which is a non- profit and independent organization that accredits and certifies nearly 21,000 health care organizations and programs in the United States, announced a new standard addressing antimicrobial stewardship for hospitals, critical care access hospitals, and nursing care centers that became effective on January 1st, 20174. As of that year, only 48 percent of hospitals had such a program5.
The Centers for Medicare and Medicaid Services (CMS) published a rule on Oct. 4th, 2016 that facilities are required to develop an Infection Prevention and Control Program (IPCP) that includes an Antibiotic Stewardship Program and to designate at least one Infection Preventionist (IP). The Antibiotic Stewardship Program was to include protocols and systems for monitoring antibiotic use and recording incidents identified under the facility’s IPCP and the corrective action, which was taken. In addition, the facility was to designate an infection prevention and control officer who is responsible for all the IPCP and who has received specialized training in infection prevention and control6.
The Affordable Care Act required that all nursing centers develop Quality Assurance and Performance Improvement (QAPI) programs. These requirements were to be enforced over three phases: phase I in Nov. 2016, phase II in Nov. 2017, and phase III in Nov. 2019. Phase II required infection control and antibiotic stewardship while phase III designates an Infection Preventionist working at least part-time in these nursing centers7.
Why do we need antimicrobial stewardship?
A small CDC study showed that 11 percent of nursing home residents were taking antibiotics on a single day and nearly 40 percent of orders for antibiotics lacked important prescribing information. The use of powerful antibiotics, such as carbapenems, has increased significantly in hospitals from 2006 to 2012. Furthermore, data indicates that roughly 30 percent of antibiotics used in hospitals are either unnecessary or prescribed incorrectly8.
During the past 30 years, antibiotic development has slowed considerably and options for treating resistant infections are becoming more limited9. Antimicrobial stewardship can provide all practitioners with tools to prevent the overuse and unintended consequences of antibiotics, combat antimicrobial resistance, and reduce healthcare costs.
What about the future?
The Developing an Innovative Strategy for Antimicrobial Resistant Microorganisms (DISARM) Act was introduced by United State Senators Johnny Isakson (R-GA) and Bob Casey (D-PA) on June 4th, 2019 to address the growing threat of infections that are increasingly becoming resistant to existing treatments. This will help with Medicare reimbursement for antibiotics and promote their appropriate use. Furthermore, this legislation has the potential to stabilize the antibiotic market, help with the development of newer drugs, and preserve the effectiveness of existing medicine10. The IDSA helped provide guidance to this legislation and is a crucial step forward to fighting antimicrobial resistance.
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