Antimicrobial Stewardship Structures/Resources

In the following audio clips, Faryal Khamis covers the essential elements of an Antimicrobial Stewardship programme.

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AMS programmes are designed to optimise the use of antimicrobials, improve patient outcomes, reduce the occurrence of resistance (and associated infections) and save healthcare cost.

A programme should have a multidisciplinary core group of team members, such as:

These team members should have support and collaboration from hospital administration staff, medical staff, leadership and prescribers.

There are six essential elements to a programme:

1) Core Strategies

2) Supplemental Strategies

3) Information Technologies

4) Microbiology Lab

5) Monitoring Processes and Outcome Measurement

6) Monthly disciplinary team meeting

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Core Strategies

These are the best interventions that address gaps in antimicrobial prescribing and should thus be a priority for any programme. Evidence shows that Prospective Audit and Feedback and Pre-Authorisation are the two most successful strategies and are the foundation interventions for any AMS programme.

Prospective Audit and Feedback – antimicrobial prescription is audited on a prospective basis and the selection of the prescription to be audited can be based on:

1) Specific Drug Prescribed

2) Location of Patient

3) Disease being treated

An audit is performed by a physician or clinical pharmacist and addresses the appropriateness of a selected agent based on microbiological data, local resistance patterns and evidence-based practices.

Audits allow teams to review antimicrobial use in real time and thus given the team the opportunity to make changes in prescribed antimicrobial regimens to optimise treatment and reach the health programme’s goal.

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Formulary Restriction and Pre-authorisation are the other core strategy.

• Formulary restriction refers to limiting a facility’s antimicrobial formulary based on factors such as efficacy, toxicity, cost and redundancy.
• Pre-authorisation is implementing a requirement to provide justification to use an antimicrobial before it is released from the pharmacy.
• Both of these strategies are effective in controlling the use of antimicrobial agents and provide the team with an opportunity to prevent the administration of even a single dose of inappropriate therapy.

Evidence suggests both strategies should be priorities for implementation, Pre-authorisation helps optimise initiation of antimicrobial whilst prospective audit/ feedback can help optimise continuing therapy.

Supplemental Strategies

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These include:

• Education
• Availability of antibiogram – based on local epidemiology (Step 2.5)
• Guidelines and clinical pathways
• Documentation of indication for antibiotics
• Streamlining/ de-escalating therapy
• Dose optimisation
• Parenteral to Oral Conversion
• Computer assisted decision support

This step has covered some core interventions that could be used in your institution. The next step will look at ways you can ensure that these interventions are prioritised and implemented in your institution.