The Role of Antimicrobial Stewardship in the Community and Hospital Settings

Antimicrobial stewardship (AMS) has a key role to play in both the hospital and the community setting. In this step, we will discuss both, but the rest of this course will focus on hospital AMS.

Separate guidelines should be put in place for both the hospital and community settings: these are both important and vary in what they need, so guidelines should be developed according to local needs. This accounts for variations in local epidemiology, drug availability/formularies, differences in who is available to join the AMS team, etc.

The Community Setting

The community setting refers to prescribing carried outside the hospital environment – this includes outpatient settings and general practice.

A large percentage of antibiotic prescribing is carried out in the community setting, and this is where many individuals are started on antibiotics when they aren’t needed.

Within community settings, there is a social pressure to prescribe unnecessarily. Antibiotics may be prescribed ‘just in case’ an infection develops – this may be due to the clinician’s concern or pressure from a patient. For example, a parent may pressure the doctor into prescribing antibiotics for their child out of concern, even if the doctor does not think this is necessary. The incidence of over-prescription can increase during months where cold and flu rates are higher – despite these being viral infections.

There is also a danger within the community where antibiotics can be purchased over the counter, without a prescription. We saw an example of this in the case study earlier this week. Risks are increased as patients may take an inappropriate choice, dose, and course length of antimicrobials.

AMS in the community setting is vital to ensure both clinicians and patients are educated on safe and appropriate antimicrobial use.

The Hospital Setting

In the hospital setting, there may also be pressure to over-prescribe – this can be from patient pressure or pressures within the hospital. The use of antibiotics can sometimes be used before diagnostic results have returned, as a ‘just in case’ measure. There is also a danger in using too many broad-spectrum antibiotics, such as carbapenems, rather than narrow-spectrum.

When antimicrobials are used, the patient should be regularly assessed to ensure the antimicrobial is still appropriate, or if changes need to be made. This will also allow clinicians to decide whether a shorter course of therapy might be more appropriate for the individual. In hospital settings, it is more common for patients to be given antibiotics for too long.

Infection control measures are also important within a hospital setting. Hospital-acquired infections (HAIs) can be dangerous, particularly in ICU settings, and so measures such as hygiene and sanitation are first-line priorities to minimise these infections. If HAIs are reduced, then there will be less need to prescribe antibiotics.

Guidelines must be put in place to keep all clinicians on track and ensure everyone understands expectations and why these are in place.