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The importance of antimicrobial stewardship

What is antimicrobial stewardship?

Antimicrobial stewardship refers to the judicious use of antibiotics. Since 2007, the Infectious Diseases Society of America (IDSA) has recommended that all hospitals implement formal antimicrobial stewardship programs (ASPs), which should consist of an infectious diseases physician and a pharmacist with training in infectious diseases. The ultimate goal of such programs is to make sure patients receive the medicines they need, while at the same time reducing the side effects and costs associated with unnecessary antibiotic prescribing.

Specific elements of antimicrobial stewardship include:

  1. Limiting inappropriate use of antibiotics.
  2. Making sure patients receive the correct dose of an antibiotic, based on the specific infection being treated, as well as the patient’s age, weight and underlying medical conditions.
  3. Knowing when antibiotics need to be given through an IV and when it is safe to give them by mouth.
  4. Knowing which conditions require long courses of antibiotics and which can be treated with shorter courses.

Why is antimicrobial stewardship important?

Worldwide, the number of infections due to antibiotic-resistant bacteria is increasing. According to the CDC, there are 23,000 deaths and two million hospitalizations attributable to drug-resistant bacteria each year in the United States. At the same time, the number of new antibiotics is dwindling. In this context, it is crucial to use our existing armamentarium appropriately. The challenge of antimicrobial stewardship is to eliminate unnecessary antibiotic use while recognizing when broad spectrum antibiotics are truly needed. It is well documented that exposure to antibiotics is associated with the development of resistance. This is especially the case of healthcare-acquired infections, which occur in patients more likely to be exposed to antibiotics. Extended courses of antibiotic therapy are also more likely to lead to resistance.

US Navy Project Hope nurse listens to a child's heartbeat while taking her vital signs. US Navy photo by Photographer's Mate 2nd Class Erika N. Jones. Public domain via Wikimedia Commons.
US Navy Project Hope nurse listens to a child’s heartbeat while taking her vital signs. US Navy photo by Photographer’s Mate 2nd Class Erika N. Jones. Public domain via Wikimedia Commons.

While antimicrobial stewardship first began at adult hospitals, there is plenty of antibiotic use among pediatric patients. For instance, more than 60% of patients admitted to children’s hospitals receive at least one antibiotic prescription, with much higher rates in children admitted to intensive care units or undergoing surgery. At the same time there, more than 49 million children receive an outpatient prescription for an antibiotic each year; about half of these are for broad-spectrum antibiotics.

How many institutions have formal antibiotic stewardship programs, and what do we know about their impact?

The number of pediatric ASPs is growing. A recent survey conducted among 38 member hospitals of the Children’s Hospital Association found that 16 had a formal ASP and 22 did not; however, 15 were planning to implement a program and most hospitals without formal ASPs were still engaged in some sort of stewardship activities. One recently published study compared antimicrobial use in children’s hospitals with formal ASPs to use in hospitals without ASPs. The authors found that antimicrobial use decreased at all study hospitals after the publication of the IDSA guidelines in 2007, but this decrease was more pronounced in hospitals with ASPs. Decreases in three specific broad-spectrum antibiotics — vancomycin, carbapenems, and linezolid — were also more pronounced in hospitals with formal ASPs.

Where should we go from here?

As noted in our recently published systematic review, there is evidence that pediatric ASPs can reduce antimicrobial utilization, antimicrobial drug costs and prescribing errors. More research needs to be done looking at the impact of antimicrobial stewardship on other outcomes such as length of stay and improved clinical outcomes.

More importantly, the practice of antimicrobial stewardship needs to grow outside of the hospital setting. It is important for physicians to remember that antibiotics do have side effects — most commonly rash and diarrhea — and that misuse may contribute to resistance. It is also important to educate patients and their families that antibiotics are not needed for every fever. For instance, antibiotics are not effective for common conditions such as runny nose, non-specific cough illnesses, and sore throat (except for strep throat).

Heading image: Clindamycin by angela_sleeping. CC BY-SA 2.0 via Flickr.

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