Antimicrobial stewardship: an essential approach to the looming crisis of antibiotic resistance
Antimicrobial stewardship is a systematic approach to optimising the use of antimicrobials in healthcare institutions. From January 2013, the presence of an antimicrobial stewardship program is a requirement for hospital accreditation, stipulated by the Australian Commission on Safety and Quality in Health Care publication Antimicrobial Stewardship in Australian Hospitals (2011).
Goals of the Metro South Health antimicrobial stewardship programs
To promote best evidence based practice in prescribing antimicrobials in order to:
- Optimise the use of antimicrobial therapy and improve patient outcomes
- Minimise inappropriate antimicrobial use
- Minimise the development of antimicrobial resistance
- Minimise antimicrobial related adverse events
- Ensure cost effective antimicrobial prescribing
Functions of the antimicrobial stewardship program
The scope and functions of the Antimicrobial Stewardship Subcommittees & Programs are to:
- Develop, implement and review the effectiveness of the Antimicrobial Stewardship Program (National Safety and Quality Health Service Standards 3.15 & 3.16)
- Develop and update the antimicrobial formulary and restriction policy, including advising the Drug and Therapeutics committee on new formulary applications for antimicrobial agents
- Oversee and monitor the Metro South antimicrobial restriction and approval system
- Develop, update and promote the antimicrobial prescribing guidelines
- Review and update unit specific antimicrobial prescribing protocols and procedures
- Liaise with microbiology to:
- Ensure susceptibility reporting is consistent with Metro South prescribing guidelines
- Monitor resistance trends and produce summary antimicrobial susceptibility data specific to Metro South hospitals and their specialist units
- Monitor and improve antimicrobial prescribing and usage through:
- Conducting antimicrobial prescribing audit and feedback exercises
- Utilisation of the Electronic Medical Record and Data Informatics
- Conducting Drug Utilisation Evaluations and other Quality Use of Medicines activities related to antimicrobial prescribing
- Review high cost antimicrobial usage
- Monitor adverse events related to antimicrobials
- Provide guidance, monitor and manage antimicrobial shortages, discontinuations and significant safety alerts
- Plan and develop antimicrobial prescribing education programs
- Promote and support clinical research and quality improvement
- Collaboration between Metro South Health Hospitals to encourage harmonisation of antimicrobial stewardship program standards and activities
Why has antimicrobial stewardship become necessary?
Modern medicine is not possible without effective antimicrobials: consider that neonatal intensive care, prosthetic joint surgery, cancer chemotherapy, organ transplantation and many other parts of modern medicine depend upon the existence effective antimicrobial therapy for either prophylaxis or treatment of complications.
Infections with antibiotic-resistant organisms are increasingly common in the community as well as in healthcare and are associated with increased morbidity and mortality. Some examples are:
- MRSA: Community strains of MRSA are currently the most common isolate from boils swabbed in EDs in Metro South. About 25% of Staph aureus bacteraemias from the community are now MRSA. In 2001, it was less than 1%.
- ESBL (Extended Spectrum Beta-Lactamase producing) E. coli is an increasingly common cause of community-associated UTI and urosepsis, and may require IV antibiotics as there are limited effective oral options. ESBL E. coli is strongly selected for by the use of ceftriaxone.
- VRE (Vancomycin-resistant E. Faecium) has become endemic in Queensland Health hospitals in the last few years and is associated with infections in cancer chemotherapy and liver transplant patients. VRE is strongly selected for by the use of ceftriaxone and vancomycin.
- NDM-1 is an antibiotic resistance gene found in gram-negative bacteria such as E. coli. It confers resistance to carbapenems (e.g. meropenem), which are usually reserved as last-line agents in serious or antibiotic-resistant infections. It was first described in 2008. It has since spread globally, including cases identified in Queensland.
- C. difficile. In North America and Europe there have been epidemics of a hypervirulent strain of C. difficile, infection which is associated with very high mortality rates. This strain is selected for by the newer broad-spectrum quinolones.
There are few new antibiotics in the development pipeline, particularly that are active against gram-negative bacteria.
Changes in institutional prescribing practices can influence local resistance rates and it has been proven that by minimising the unnecessary prescription of antibiotics, the progression towards more resistance can be slowed, hopefully until either new antimicrobials or other new approaches such as vaccines can be developed.
Therefore only judicious, evidence-based use can be justified. Antibiotics that are less likely to select for multi-resistant organisms should be preferentially used when the safety of the patient isn’t compromised by doing so.