Elsevier

Mayo Clinic Proceedings

Volume 86, Issue 11, November 2011, Pages 1113-1123
Mayo Clinic Proceedings

SYMPOSIUM ON ANTIMICROBIAL THERAPY
Antimicrobial Stewardship

https://doi.org/10.4065/mcp.2011.0358Get rights and content

Antimicrobial resistance is increasing; however, antimicrobial drug development is slowing. Now more than ever before, antimicrobial stewardship is of the utmost importance as a way to optimize the use of antimicrobials to prevent the development of resistance and improve patient outcomes. This review describes the why, what, who, how, when, and where of antimicrobial stewardship. Techniques of stewardship are summarized, and a plan for implementation of a stewardship program is outlined.

Section snippets

WHY DO WE NEED ANTIMICROBIAL STEWARDSHIP?

In the early days of antibiotics, booming drug development meant that even when resistance developed, a new drug was always available to treat the increasingly resistant bacteria. Fourteen new classes of antibiotics were introduced between 1935 and 2003. However, rapid antimicrobial development came with a cost—antimicrobial resistance. In the hospital, resistance to antibiotics and antifungals poses the greatest concern. In 2003, US intensive care units (ICUs) reported to the Centers for

WHAT IS ANTIMICROBIAL STEWARDSHIP?

Until this next giant step is achieved, those of us not developing new drugs have another job: conserve the antibiotics we have. In the hospital, antimicrobial stewardship teams are charged with this important initiative. Antimicrobial stewardship has been defined as “the optimal selection, dosage, and duration of antimicrobial treatment that results in the best clinical outcome for the treatment or prevention of infection, with minimal toxicity to the patient and minimal impact on subsequent

WHO: BUILDING THE STEWARDSHIP TEAM

Every hospital should work within its resources to create an effective team given its budget and personnel constraints. The stewardship team does not have to fit a particular mold, and it would be a mistake to delay implementation of a stewardship program because of a lack of availability of one or more of the typical team participants listed subsequently. Most stewardship teams include either an infectious disease physician or a pharmacist (with or without specialized training in infectious

Approaches

There are 2 major approaches to antimicrobial stewardship, with the most successful programs generally implementing a combination of both. The front-end or preprescription approach to stewardship uses restrictive prescriptive authority. Certain antimicrobials are considered restricted and require prior authorization for use by all except a select group of clinicians. Clinicians without authority to prescribe the drug in question must contact the designated antimicrobial steward and obtain

Understand Problem Pathogens and Antimicrobial Use at Your Institution

An important first step in building an ASP should be to identify current institutional resistance patterns and antimicrobial use. Not all hospitals need the same level of interventions. Antimicrobial stewardship programs should be tailored to institutional problem pathogens and overuse of particular classes of drugs. Engage your microbiology laboratory, infection control, and pharmacy colleagues.

Assess Your Current Resource

Before funding can be secured for your ASP, it is crucial to understand what systems are in place

WHERE CAN THINGS GO WRONG: BARRIERS AND PITFALLS

One of the greatest challenges of antimicrobial stewardship research is demonstrating a clear causal association between implementation of ASPs and decreased rates of antimicrobial resistance. Early studies that achieved decreased cephalosporin use were successful in controlling the incidence of resistant gram-negative infections to cephalosporins but resulted in an increase in carbapenem use and resistance to carbapenems.71 This is an example of the “squeezing the balloon” phenomenon, in which

CONCLUSION

As hospitalized patients become more complex to treat, the increasing prevalence of antimicrobial resistance in both health care and community settings represents a daunting challenge. With the increasing complexity of infections and a paucity of new antimicrobials in development, the future of successful antimicrobial therapy looks bleak. Antimicrobial stewardship can provide all practitioners with tools to prevent the overuse of valuable resources and help control the increase in

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    The authors have no conflict of interest to disclose.

    Individual reprints of this article and a bound reprint of the entire Symposium on Antimicrobial Therapy will be available for purchase from our Web site www.mayoclinicproceedings.com.

    On completion of this article, readers should be able to: (1) describe the goals of antimicrobial stewardship and discuss why there is an increasing need for antimicrobial stewardship programs; (2) identify stewardship techniques that can be used in a variety of hospital settings by different health care practitioners; and (3) list steps for starting a stewardship program and identify potential barriers to implementation.

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