Implementation of a stewardship programme

Through this course, it has been understood that antimicrobial resistance is a significant threat to human health. We have discussed antimicrobial stewardship in steps 1.14 and 1.15.

Now, Professor Dimitri Beeckman will discuss how to actually implement these stewardship practices and why this is so important in our fight against antimicrobial resistance.

Why do we need to implement a stewardship programme?

As seen in step 1.8, we have had a golden age of antibiotic discovery. This led to a widespread use of antibiotics. As years passed and technology improved, antibiotics have been made to be safe to use, very effective, and relatively inexpensive. More importantly, millions of lives have been saved.

On the downside, antibiotics have been used inappropriately – they have been misused through use without a prescription and overused for self-limiting infections.

The aim of implementation of stewardship programmes is to provide practical recommendations to improve the quality of antibiotic prescribing and thereby improve patient clinical outcomes.

Some facts about antibiotic use

• Approximately 30% of all hospitalised inpatients at any given time receive antibiotics.

• Over 30% of antibiotics are prescribed inappropriately in the community.

• Up to 30% of all surgical prophylaxis is inappropriate.

• Approximately 30% of hospital pharmacy costs are due to antimicrobial use.

• 10-30% of pharmacy costs can be saved by antimicrobial stewardship programs.

Principles involved

The key principles of a stewardship program are to maintain long-lasting effectiveness of antimicrobial agents, to complementarily-implement activities focused on decreasing the use of inappropriately used antimicrobials, and to reduce the spread and transmission of resistant microorganisms.

We aim to have the following declared in policy documents: council recommendations on prudent use of antimicrobial agents in human medicine and council recommendations on patient safety including ‘Prevention and control of healthcare-associated infections’.

Content of an AMS programme

Implementation involves using appropriate standards and measurable elements while carrying out stewardship programmes. The main objectives are:

• Ensuring effective, safe and cost-effective antibiotic treatment and prophylaxis of infections.

• Prevention and control of antimicrobial resistance by means of prudent use of antibiotics.

• Reduction in occurrence of difficult-to-treat infections caused by multi drug-resistant microorganisms.

It must be an interdisciplinary programme at organisational level. There must be an organisational structure to lead the programme – specification of scope, functions, activities, competencies, leadership and accountability. It should have sufficient capacity (human, material and technical) and basic tools.

Epidemiological surveillance of antimicrobial resistance is very important. Systematic evaluation of quality of antibiotic usage, based on relevant scientific knowledge and focused on identification of inappropriate practice, should be done regularly. Continuous quality improvement should be worked on regarding capacity building, structure, organisation, functions and effectiveness based on implementation of action plans.

Key recommendations

• Having an interdisciplinary team of experienced specialists representing appropriate disciplines, such as clinical microbiology, infectious diseases, intensive care, surgery, hospital pharmacy, infection control and any other clinical disciplines as appropriate, is crucial in successful implementation.

• Competent professionals regularly process, evaluate, compare and interpret local data regarding clinically and epidemiologically important patterns of antimicrobial resistance.

• The generic list of essential antimicrobial agents (with scope, spectrum and epidemiological characteristics) should be constantly updated.

• Categorisation of restricted drugs should be included.

• Information about pricing and dosage must be added.

• Regular training of prescribing physicians and other relevant healthcare workers in diagnostics, treatment and prophylaxis of infections is significant. This training must be focused on appropriate use of antimicrobial agents as well as prevention and control of antimicrobial resistance. It must have information on recent problems of antimicrobial resistance, inappropriate use of antimicrobials and adequate control measures for improvement.

• Antibiotic lists are very helpful. Local guides for diagnostics of infections including microbiology laboratory, initial antimicrobial therapy, pathogen-specific antimicrobial therapy, surgical prophylaxis should be referred to. In a way, they become tools for controlling antibiotic consumption and preventing antimicrobial resistance.

Implementation types

• Persuasive methods: Educating the clinician and encouraging optimal treatment, broadly advising clinicians about how to prescribe, or giving feedback on their prescribing.

• Restrictive methods: Administratively constrain how clinicians may prescribe, such as by limiting access to specific antibiotic agents, or by instituting automatic stop orders or time limits for antibiotic treatments.

A meta-analysis of 89 studies from 19 countries found that each approach could improve prescribing, reduce antibiotic resistance, and decrease the number of hospital-acquired infections. Available data suggest that persuasive interventions are less effective in the short term than restrictive methods, but may have a greater long-term effect on prescribing practices.

Summary

The steps for a successful programme according to the Centers for Disease Control and Prevention (CDC).