AMS objectives, goals, and impact

So, now you understand what AMS is: “a coherent set of actions which promote the responsible use of antimicrobials.” But how do we know what actions we should be taking?

In this section, we will explore the objectives, goals, and timelines that determine what actions we will take to promote the responsible use of antimicrobials and, most importantly, measure the impact of our actions.

Objectives

We have talked previously about the need for AMS. Antibiotics are overprescribed globally, yet many patients who need antibiotics are not receiving them.

Therefore, the core objective of AMS is to reduce antibiotic usage and align usage with actual needs.

In addition to this core objective, there are several other objectives for AMS:

• To change prescribing practices and use of antibiotics (particularly by optimising antibiotic treatment and prophylaxis.
• To extend the lifespan of existing antibiotics.
• To reduce the development of AMR.
• To improve the quality of healthcare.
• To save patient lives and healthcare costs by only using the right antibiotics when needed.

Goals

There are three main goals for antimicrobial stewardship programmes (ASPs). Depending on the clinical setting, ASPs will target their goals based on available resources and current short-, mid-, and long-term opportunities, as demonstrated in the diagram below. These timelines of when different goals may be achieved are important to communicate the potential benefits of an ASP to key stakeholders.

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The image below summarises the ‘five rights’ of antibiotic prescribing, which are the goals of AMS and their positive impacts, and how they can help prevent unintended consequences of antibiotic overuse, such as; increased costs, negative effects on patient health, or increased resistance.

Measuring the Impact of an ASP

Systematic reviews and meta-analyses are the most robust methods of evaluating the impact of AMS interventions. They can address a range of outcomes such as clinical, microbiological, and economical. Below we will explore the impacts of ASPs from various systematic reviews.

Cost effectiveness (Nathwani et al. 2019. and the OECD)

• ASPs reduce hospital, antimicrobial, and patient costs.
• Patient outcomes improve due to reduced length of stay and infection-related re-admissions.
• The Organisation for Economic Co-operation and Development (OECD) predicts savings of $1.2 million PPP (purchasing power parities) if you implement healthcare-based interventions such as improved hand and environmental hygiene and ASPs.
• PPP is used to adjust US Dollars for differences in price across countries.

Patient outcomes (Schuts et al. 2016)

The 3 AMS interventions that have a clear impact on reducing mortality are:

• Compliance with guidelines.
• De-escalation based on cultures.
• Review of bacteraemia (e.g. S. aureus) by an infection management expert.

Intravenous to Oral Switch Therapy (IVOST) is also a good practice, but the study does not show a statistically significant reduction in mortality. To find out more about IVOST, please access the BSAC FutureLearn course on this topic.

Antimicrobial resistant organisms (Baur et al. 2017)

• ASPs reduce the incidence of infection with antibiotic-resistant organisms.
• ASPs reduce colonisation with antibiotic-resistant organisms.
• ASPs reduce C. difficile infection.

Improved stewardship (2017 Cochrane Review)

The findings from this review are as follows:

• Hospital AMS interventions are effective in increasing compliance with antibiotic policy- 15% increase in compliance with a range of processes.
• Hospital AMS interventions effectively reduce the duration of treatment (reduction of 1.95 days of antibiotic treatment).
• Reducing antibiotic use does not increase mortality.
• Reducing antibiotic use reduces the length of stay (reduction of 1.12 days in inpatient stay).

In the next section, we will look at the impacts of ASPs in low and middle-income countries (LMICs).

What is the impact of ASPs in low and middle-income countries (LMICs)?

A key finding from the 2017 Cochrane review was a lack of high-quality data showing the impact of ASP in LMICs- highlighting the need for more research into this area. Below are some studies which address the impact of AMS in LMICs.

Beneficial impact of AMS (Van Dijck et al. 2018)

• This study included 27 studies from 2 low-income and 11 middle-income countries.
• Most studies regarding LMICs show a beneficial impact of AMS, but the low quality of studies and heterogeneity of interventions and outcomes cannot provide significant or firm conclusions.
• However, the trend does appear to support the benefit of AMS interventions with improvements to prescribing and clinical outcomes.

Positive impact of AMS in children (Abo et al. 2022)

• From a meta-analysis looking at the impact of AMS in children, interventions were found to have a positive impact.
• Interventions include AMS bundles, clinical decision tools, implementation of guidelines, financial disincentives for antibiotic prescribing, audits and feedback.
• AMS interventions resulted in reduced clinical infections, reduced clinical failure, and a reduced MDRO colonisation rate.
• There was no increase in mortality or length of stay.

Limitations of ASPs in LMICs (Brinkmann and Kibuule 2019)

• This study of AMS implementation in primary health care facilities in Namibia showed a suboptimal implementation of AMS practice.
• The main challenge is the lack of policies and systems specific to antimicrobial use as well as a commitment of financial and human resources to implement AMS programmes in primary health care.

In 2021 the WHO produced policy guidance on integrated antimicrobial stewardship activities. This document responds to a demand on how to facilitate the implementation of national AMS activities in an integrated and programmatic approach. The WHO suggest that the implementation of integrated AMS interventions and activities requires a programmatic approach anchored in public health principles. The following five pillars represent the key package that needs to be considered to commence and implement comprehensive and integrated AMS activities.

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