Key antibiotic stewardship issues
In the video, you may have noted some of the following antibiotic stewardship issues:
- Appropriate cultures not always sent prior to commencing antibiotic therapy
- Poor adherence with the hospital’s antibiotic guidelines (prophylaxis and treatment) with use of broad-spectrum antibiotics
- Poor working relationships between the ward doctors and pharmacists; doctors behaving paternalistically and not working as a multidisciplinary team
- Lack of engagement and a working relationship between the surgical and antimicrobial management teams
- Lack of leadership within the antimicrobial management team
- The hospital’s microbial epidemiology showed there was an increasing problem, but this was not responded to in a timely manner.
Often, antibiotic stewardship is only adequately considered once an unanticipated ‘crisis’ occurs; for example, a local increase in the incidence of antibiotic resistant infections, as in the outbreak scenario, or, at a national level, concern from patients, relatives, media and/or others. Although the hospital in the video had an antimicrobial management team (AMT), warning signs either went unnoticed and/or were not responded to resulting in a crisis.
Although all antibiotic use has an ecological impact, in general, broad-spectrum antibiotics such as fluoroquinolones, beta-lactam/beta-lactamase inhibitors, cephalosporins and carbapenems, are more likely to select for multi-drug resistant bacteria, and trigger Clostridium difficile due to their greater impact on the gastrointestinal microbiome, compared to narrower spectrum agents such as benzylpenicillin, trimethoprim and tetracyclines.
The use of broad-spectrum agents should be limited to patients who have severe or antibiotic resistant infections requiring their use. Whenever it is possible and clinically safe to do so, the narrowest spectrum antibiotic agent available should be used. Appropriate microbiological tests should be performed prior to commencing antibiotic therapy whenever possible in order to guide on going therapy as well as providing important epidemiological surveillance data.
At the ward level, it is vital that doctors and pharmacists, who both have different skills that are key to prescribing antibiotics optimally, work together harmoniously as equal partners.
At the organisational level, antibiotic management teams must develop functional and respectful relationships with clinical teams in order to, for example, optimise adherence to organisational antibiotic guidelines and respond effectively when this is not the case.
Measuring and monitoring antibiotic use over time, preferably combined with local surveillance of microbial epidemiology, is a fundamental component of effective antibiotic stewardship, potentially allowing the early response to a problem before a crisis occurs. This component of stewardship will be considered further in week 3.
Other problems that you may have identified, but are more relevant to the infection prevention and control team (IP&C) are:
- hand-washing (the patient’s wife recognised this to be sub-optimal)
- patient-to-patient contact encouraged by staff
- catheter insertion technique.
It is important to emphasise that the AMT and IP&C, however, should work together closely with overlapping membership and governance; some organisations have integrated these teams for this reason.
© UoD and BSAC