Antibiotic Stewardship

Managing Responsible Antimicrobial Use & Its Increasing Importance in Public Health

Once antibiotics became widely available, the leading causes of death in many countries shifted from communicable diseases like diphtheria, cholera and tuberculosis to non-communicable diseases, increasing life expectancy.¹ Since then, antibiotics have been used to treat a wide range of diseases, preventing the spread of infection and reducing the risk of complications in hospitalized patients.

Despite the many benefits of antibiotics, overexposure to these "wonder drugs" has created a public health crisis: antibiotic resistance. In the primary care setting, inappropriate prescribing practices lead to increased antimicrobial exposure by making antibiotics available to patients who don't need them.² The use of broad-spectrum antibiotics also contributes to the problem by allowing antibiotic-resistant microbes to multiply and become dominant.

In hospitals, antibiotics are used to treat critically ill patients and prevent infections following complex surgical procedures. Although many patients need antibiotics to recover from their illnesses and injuries, antibiotic-resistant organisms spread easily from one patient to another, especially in hospitals with open wards instead of private or semi-private rooms.

Antibiotic-resistant bacteria also make their way into hospital waste, allowing them to spread into the community at large.³

Antibiotic resistance makes it more difficult to treat bacterial infections, leading to lengthy hospital stays and increased medical costs. In some cases, antibiotic resistance increases the risk of death from bacterial pneumonia and wound infections. As a result, the World Health Organization refers to antibiotic resistance as "one of the biggest threats" to human health in existence.⁴

Although antibiotic resistance is a major public health concern, there are ways to prevent the problem from getting worse. One of the best options is to implement antibiotic stewardship programs in hospitals. These programs encourage responsible antibiotic use, reducing the spread of drug-resistant organisms and protecting patients from infections that are difficult and expensive to treat.

Core Elements of Antibiotic Stewardship Programs in Hospitals

Every successful antibiotic stewardship program has several elements in common. One of the most important is strong leadership commitment. Hospital leaders should support the efforts of antibiotic stewardship programs by making financial and technological resources available for education, training and monitoring initiatives. At the department level, managers can contribute to the success of antibiotic stewardship programs by giving staff members time to participate in program-related activities. Hospital human resources professionals should also consider adding stewardship-related duties to clinical job descriptions to communicate a facility's dedication to reducing inappropriate antibiotic use.

Key Personnel

It's also important to appoint a single leader to manage the program. Large, well-funded facilities may hire a full-time leader with experience managing successful initiatives, while smaller facilities with more limited financial resources may have a current employee take on the role of program leader in addition to other duties. Appointing a pharmacist co-leader is also recommended, as pharmacists play an important role in dispensing antibiotics safely and educating others on the risks of inappropriate prescribing.⁵

Key Activities

One of the most critical components of an antibiotic stewardship program is implementing actions that can help prevent inappropriate antibiotic use. This can include implementing the use of antibiotic "timeouts," which give the treating provider an opportunity to assess a patient's response to antibiotics and determine if continuing antibiotic therapy is needed. If it is, the provider should also use the timeout to determine whether to continue using the same drug or prescribe a different antibiotic. Every antibiotic stewardship program should also include tracking, reporting and education components.

Understanding Risks of Antimicrobial Use at Your Institution

Antibiotic-resistant organisms are more common in health care facilities than in other settings, putting patients at risk for serious infections and resulting in poorer patient outcomes.⁶ One of the reasons why antibiotic resistance is such a concern for medical professionals is because hospitalized patients receive hands-on care from physicians, nurses, respiratory therapists and other staff members, allowing antibiotic-resistant organisms to spread quickly.

Hospitalized patients, especially the ones admitted to intensive care units, also undergo a variety of procedures that cause antibiotic-resistant organisms to spread to health care providers, visitors and other patients. For example, some patients develop infections after central line placement; these infections are often difficult to treat and may involve antibiotic-resistant organisms.

In addition to concerns regarding antibiotic resistance, the use of antimicrobials in hospitals increases the risk of serious allergic reactions, nerve damage and problems with the tendons. Yeast infections and gastrointestinal discomfort are also common side effects of antibiotic use in health care settings.

Examples of Antibiotic Stewardship Interventions

Some antibiotic stewardship interventions are deployed before antibiotics are prescribed, while others occur after a patient has already started taking antibiotics. Many initial interventions focus on educating clinicians, patients and members of the public on the risks associated with inappropriate antibiotic use.⁷ Hospitals also use antibiograms to aid clinicians in choosing appropriate antibiotics for their patients. Antibiograms provide information about susceptibility to a range of antibiotics, allowing physicians and other health care providers to prescribe the antibiotic that's most likely to treat an infection successfully.

Some hospitals are also fighting the problem of antibiotic resistance by creating lists of restricted antimicrobials and working to ensure that patient charts contain accurate information regarding antibiotic allergies. When an antibiotic is added to a list of restricted antimicrobials, that doesn't mean it can never be prescribed. Instead, use of the drug requires prior authorization, ensuring that only patients who really need the antibiotic receive it. In high-income countries, many patient charts are labeled with allergy warnings that turn out to be inaccurate. A study published in BMJ Global Health indicates that 90% to 95% of penicillin allergy labels are spurious, making the problem of antibiotic resistance even worse.⁸

Once antibiotics have been prescribed, dose optimization, duration optimization and timeouts are among the most common interventions. Dose optimization involves determining exactly the right dose of an antibiotic to administer to each patient. If the dose is too small, the risk of antibiotic resistance increases, but larger doses may lead to uncomfortable side effects. Duration optimization involves determining the right length of treatment. If a patient stops taking an antibiotic after a few days, remaining bacteria may become resistant to antimicrobials. Taking antibiotics for too long, however, increases the risk of adverse events.⁹

Some hospitals are using a highly effective intervention known as procalcitonin testing. Procalcitonin is a biomarker that can be used to determine if a patient is likely to have a bacterial infection and, if so, the seriousness of the infection.¹⁰ If a high-risk patient has signs of infection, PCT testing makes it easier for clinicians to determine if antibiotic therapy is required. For patients already receiving antibiotics, the test is a safe way to determine the right time to discontinue antibiotics. As a result, PCT testing is a valuable tool for optimizing the duration of antimicrobial use in a hospital setting.

PCT testing has been used to promote antibiotic stewardship in the treatment of sepsis, community-acquired pneumonia and SARS-CoV-2 patients.¹¹ In the PROGRESS study, the use of PCT testing reduced the median antibiotic treatment duration by 50% (reducing it from 10 days to 5 days), reduced the 28-day mortality rate by 46% and drove down the costs of hospitalization by 19%, demonstrating the benefits of incorporating this type of testing into an antibiotic stewardship program.¹²

Building Your Stewardship Team

After establishing an effective leadership team, it is critical to get support from laboratory staff, nurses, epidemiologists and IT employees. Laboratory team members are key contributors because they can optimize the flow of information from labs to clinical decision-makers. Nurses are well-positioned to fight antibiotic resistance by getting blood cultures before administering antibiotics, educating patients about the dangers of inappropriate antibiotic use and discussing antibiotic treatment with physicians and other health care providers.

Epidemiologists are major contributors to the success of antibiotic resistance programs, as they can use their analytical skills to identify concerning trends and determine the best way to use antibiotics without making the problem of antibiotic resistance even worse. IT professionals make it possible for these employees to carry out their stewardship duties by providing access to technological resources that can be used to optimize workflow, provide point-of-care decision support and collect data on antibiotic use in hospitals.

How to Implement Antibiotic Stewardship in Your Hospital

For hospitals interested in implementing antibiotic stewardship, it's important to get the right people in place and determine the most effective interventions. After establishing the leadership team and educating department employees on the importance of antibiotic stewardship, the next step is to look for ways to optimize antibiotic use. Some interventions are infection-specific. This includes reviewing cases of any suspected community-acquired diagnosis after 48 hours to determine if the patient's symptoms are caused by bacterial pneumonia or a non-infectious disease.

Hospitals should develop guidelines to help clinicians identify wounds that need to be treated with antibiotics instead of other medications. To reduce antibiotic use among patients with suspected urinary tract infections, the antibiotic stewardship team should create a policy advising health care providers to order antibiotics only when patients have active signs of a UTI.¹³ These symptoms can include increased urinary frequency, pain while urinating and blood in the urine.

Antibiotic stewardship teams should also develop institutional policies to ensure clinicians and other staff members understand the importance of appropriate prescribing. Hospital executives can strengthen these efforts by releasing a statement on the importance of antibiotic stewardship and publishing the statement in annual reports and other critical documents.¹⁴ Support from executives and hospital boards can help promote buy-in among employees, increasing the effectiveness of antibiotic stewardship efforts.

Cost-Effectiveness of Antibiotic Stewardship in Your Hospital

Although a successful antibiotic stewardship program requires a significant investment of resources, it's a cost-effective way to reduce antibiotic resistance and improve patient outcomes.¹⁵

In a systematic review of research related to antibiotic stewardship programs, Nathwani et al. determined that 69% of included studies showed that implementing antibiotic stewardship programs resulted in reduced operational costs for hospitals.¹⁶ Cost savings were the highest in facilities that focused on altering antibiotic therapy guidelines and creating lists of restricted antibiotics requiring preauthorization for use.

A meta-analysis of U.S.-based hospitals found significant savings on a per-patient basis, as well, with costs declining over $11,000 per sepsis patient and nearly $3,000 per LRTI patient in hospitals implementing PCT-aided antibiotic stewardship programs.¹⁷ The study found further impact from such programs, including decreased length of stay and decreased rates of C. diff.