A Call to Arms: The Imperative for Antimicrobial Stewardship

Department of Medicine and Epidemiology, Johns Hopkins University School of Medicine, Baltimore, Maryland 21205, USA.
Clinical Infectious Diseases (Impact Factor: 8.89). 08/2011; 53 Suppl 1(Suppl 1):S4-7. DOI: 10.1093/cid/cir362
Source: PubMed


Antimicrobial resistance is a major public health crisis. The prevalence of drug-resistant organisms, such as the emerging NAP1 strain of Clostridium difficile, now highly resistant to fluoroquinolones, Acinetobacter species, Klebsiella pneumoniae carbapenemase-producing organisms, and methicillin-resistant Staphylococcus aureus, is increasing nationwide. The sources of antimicrobial resistance are manifold, but there is a well-documented causal relationship between antimicrobial use and misuse and the emergence of antimicrobial-resistant pathogens. As the development of new antimicrobial agents is on the decline, the medical community, across all specialties and in conjunction with public health services, must develop and implement programs and strategies designed to preserve the integrity and effectiveness of the existing antimicrobial armamentarium. Such strategies are collectively known as antimicrobial stewardship programs and have the potential to minimize the emergence of resistant pathogens.

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    • "The implication is that only a minority of skin infection patients treated as outpatients require coverage for CA-MRSA. Despite this, use of such antibiotics in this group has increased, reaching 38% of all antibiotic regimens among ED patients with skin infection by 2005.1 Overuse of antibiotics is an important public health and quality issue because it causes antimicrobial resistance, and adverse events such as Clostridium difficile colitis.5 "
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    ABSTRACT: Introduction: National guidelines suggest that most skin abscesses do not require antibiotics, and that cellulitis antibiotics should target streptococci, not community-associated MRSA (CA-MRSA). The objective of this study is to describe antimicrobial treatment of skin infections in U.S. emergency departments (EDs) and analyze potential quality measures. Methods: The National Hospital Ambulatory Medical Care Survey (NHAMCS) is a 4-stage probability sample of all non-federal U.S. ED visits. In 2007 NHAMCS started recording whether incision and drainage was performed at ED visits. We conducted a retrospective analysis, pooling 2007-2010 data, identified skin infections using diagnostic codes, and identified abscesses by performance of incision and drainage. We generated national estimates and 95% confidence intervals using weighted analyses; quantified frequencies and proportions; and evaluated antibiotic prescribing practices. We evaluated 4 parameters that might serve as quality measures of antibiotic stewardship, and present 2 of them as potentially robust enough for implementation. Results: Of all ED visits, 3.2% (95% confidence interval 3.1-3.4%) were for skin infection, and 2.7% (2.6-2.9%) were first visits for skin infection, with no increase over time (p=0.80). However, anti-CA-MRSA antibiotic use increased, from 61% (56-66%) to 74% (71-78%) of antibiotic regimens (p<0.001). Twenty-two percent of visits were for abscess, with a non-significant increase (p=0.06). Potential quality measures: Among discharged abscess patients, 87% were prescribed antibiotics (84-90%, overuse). Among antibiotic regimens for abscess patients, 84% included anti-CA-MRSA agents (81-89%, underuse). Conclusion: From 2007-2010, use of anti-CA-MRSA agents for skin infections increased significantly, despite stable visit frequencies. Antibiotics were over-used for discharged abscess cases, and CA-MRSA-active antibiotics were underused among regimens when antibiotics were used for abscess. [West J Emerg Med. 2014;15(3):282-289.].
    The western journal of emergency medicine 05/2014; 15(3):282-9. DOI:10.5811/westjem.2013.8.18040
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    • "Overutilization of antimicrobial agents is recognized as a significant contributor to the development of antimicrobial resistance.1 Unfortunately, multi-drug resistance has already emerged in a number of species and there are few antimicrobials in the development pipeline, making this a mounting public health concern. "
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    ABSTRACT: In an era of increasing antimicrobial resistance and few antimicrobials in the developmental pipeline, many institutions have developed antimicrobial stewardship programs (ASPs) to help implement evidence-based (EB) strategies for ensuring appropriate utilization of these agents. EB strategies for accomplishing this include formulary restriction with prior authorization. Potential limitations to this particular strategy include delays in therapy, prescriber pushback, and unintended increases in use of un-restricted antimicrobials; however, our ASP found that implementing prior authorization for select antimicrobials along with making a significant effort to educate clinicians on criteria for use ensured more appropriate prescribing of these agents, hopefully helping to preserve their utility for years to come.
    Virulence 11/2012; 4(2). DOI:10.4161/viru.21657 · 4.22 Impact Factor
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    • "Antimicrobial stewardship has been promoted for all hospitals to help cope with the challenges of CDI and emerging resistance to antibiotics [6-8]. In 2007, the Infectious Diseases Society of America (IDSA) and the Society for Healthcare Epidemiology of America (SHEA) published revised guidelines for developing institutional programs to enhance antimicrobial stewardship [9]. "
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    ABSTRACT: Background Antimicrobial stewardship has been promoted as a key strategy for coping with the problems of antimicrobial resistance and Clostridium difficile. Despite the current call for stewardship in community hospitals, including smaller community hospitals, practical examples of stewardship programs are scarce in the reported literature. The purpose of the current report is to describe the implementation of an antimicrobial stewardship program on the medical-surgical service of a 100-bed community hospital employing a core strategy of post-prescriptive audit with intervention and feedback. Methods For one hour twice weekly, an infectious diseases physician and a clinical pharmacist audited medical records of inpatients receiving systemic antimicrobial therapy and made non-binding, written recommendations that were subsequently scored for implementation. Defined daily doses (DDDs; World Health Organization Center for Drug Statistics Methodology) and acquisition costs per admission and per patient-day were calculated monthly for all administered antimicrobial agents. Results The antimicrobial stewardship team (AST) made one or more recommendations for 313 of 367 audits during a 16-month intervention period (September 2009 – December 2010). Physicians implemented recommendation(s) from each of 234 (75%) audits, including from 85 of 115 for which discontinuation of all antimicrobial therapy was recommended. In comparison to an 8-month baseline period (January 2009 – August 2009), there was a 22% decrease in defined daily doses per 100 admissions (P = .006) and a 16% reduction per 1000 patient-days (P = .013). There was a 32% reduction in antimicrobial acquisition cost per admission (P = .013) and a 25% acquisition cost reduction per patient-day (P = .022). Conclusions An effective antimicrobial stewardship program was implemented with limited resources on the medical-surgical service of a 100-bed community hospital.
    10/2012; 1(1):32. DOI:10.1186/2047-2994-1-32
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