Introduction
Since the discovery of penicillin, antibiotics have become an important part of global health. Antibiotics are common medications that are used in modern healthcare. These medications fight against bacterial infections in humans and animals—these either work by inhibiting bacterial growth and multiplication or killing the bacteria.
AMS (antimicrobial stewardship) refers to the optimal selection, optimal dosing, and duration of treatment that brings the best clinical outcomes with the least adverse effects to the patient and the most negligible impact on subsequent resistance. AMS is one of the important approaches needed for strengthening the healthcare system; the other two are infection prevention and control and medicine safety.
What Are the Goals of Antibiotic Stewardship?
The goals of the AMS program are:
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To minimize antibiotic-related adverse effects.
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To lower antibiotic resistance.
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To reduce healthcare costs.
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Prevention of antimicrobial overuse, abuse, or misuse.
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To assist healthcare providers in prescribing the correct drug, right dose, right duration, correct drug route, and de-escalation to pathogen-related therapy.
What Are the Core Elements of Antibiotic Stewardship?
The core elements of the AMS program are:
1. Leadership Commitment:
Leadership commitment is important for the AMS program. Leadership support can be of different forms:
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Formal statements to monitor and improve antimicrobial use.
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Dedicate information technology and financial resources to the program.
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Support education and training and ensure the staff gets sufficient time for stewardship activities.
2. Accountability:
A single leader is identified as a stewardship program leader who will be responsible for the program's outcome. Physician leaders are seen to have highly successful programs. Appointing a pharmacist as a co-leader further improves the outcome.
3. Stewardship Expertise:
Ensure that the AMS program leaders and co-leaders have the education and expertise to implement the intervention programs. The strategies to ensure stewardship expertise include:
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Those with training and experience in antibiotic stewardship and infectious diseases are appointed leaders and co-leaders (mostly physicians and pharmacists).
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Stewardship leaders and co-leaders are provided access to remote stewardship experts.
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An external multidisciplinary advise group is appointed to support the co-leads and leaders in developing stewardship strategies.
4. Action: The action involves implementing policies that support optimal antibiotic use. Interventions directed towards antibiotic stewardship are categorized as:
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Pharmacy-driven interventions are mainly for dose optimization based on drugs, organ dysfunction, and therapeutic drug monitoring.
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Broad interventions include prior authorization, antibiotic time-out, etc.
5. Tracking:
Keeping track of the evaluation of implementation policies and outcomes is important for identifying areas of improvement.
6. Reporting:
This involves reporting data on antibiotic use and stewardship activities to healthcare providers, stewardship collaboratives, the public, and health department leaders.
7. Education:
Healthcare professionals and the public receive antibiotic stewardship education to optimize antibiotic use. The educational strategies that can be considered include:
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Antibiotic stewardship education workshops are provided on a setting-specific basis.
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A public communication strategy that involves engaging with social media posting and local news channels may be developed.
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Conducting student work-study programs.
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Outreach health care providers in remote areas with limited educational resources.
What Is the Clinical Significance of Antibiotic Stewardship?
The healthcare system has been transformed with the introduction of antibiotics; infections once considered lethal became treatable with antibiotics. Antibiotics have also made other advancements like organ transplants and cancer chemotherapy possible. Proper initiation of antimicrobial therapy has significantly reduced morbidity and mortality.
However, estimates suggest that most antibiotics prescribed are either suboptimal or unnecessary. Due to the emerging antibiotic resistance, the antibiotics that were once in use are no longer as effective as they were. Like all drugs, antibiotics, too, have side effects. Antibiotics are effective against bacterial infections like E. coli, urinary tract infections, strep throat, etc. Some infections, like ear and sinus infections, may not require antibiotics. Reactions related to antibiotics result in one in five medication-related visits to the emergency department, and children are the most typical causes of medication-related visits to the emergency department. Therefore, antibiotics are to be taken only under the guidance of a healthcare provider; unnecessarily taking antibiotics may not be beneficial and can result in side effects.
The AMS program aims to reduce antibiotic use, provide cost-effective medical care, and improve patient care. Studies show that reducing excessive antibiotic prescriptions in inpatient individuals helps lower AMS and nosocomial infections (healthcare-related infections).
As per the CDC (Center for Disease Control and Prevention) Antibiotic Resistance Threat Report 2019, there has been a decline in deaths from AMR compared to the 2013 report.
In Which AMS Program Success Can Be Improved?
The AMS program's success can be improved through interdepartmental coordination and communication. The success is linked to the core elements of AMS.
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All clinicians should support antibiotic optimization, especially primary care physicians and hospitalists. The prescribers should follow the 5 “D”s of AMS. These are correct Dose, right Drug, suitable Duration, correct Drug route, and De-escalation of pathogen-directed therapy.
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Nurses play an important role in patient education and in optimizing diagnostic tests. Examples include timely collection of cultural samples before antibiotic administration, educating patients on how to take antibiotics, etc.
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Pharmacists are also an important part of the team. They also educate patients on medications.
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Epidemiologists and infection control and prevention teams analyze, track, and report antibiotic resistance and adverse effects.
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Lab staff plays a role in diagnostic stewardship by assisting in properly using the test. They also assist in creating local anti-micrograms that help in optimizing antimicrobial prescription.
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Information technology personnel play an important role in incorporating protocols into stewardship programs, such as developing prompts to review antimicrobials.
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At the individual level, the patient should take the antimicrobial responsibly. The patient should take the antibiotic as and when prescribed by the physician and avoid storing unused antimicrobials for future use.
Conclusion
Antibiotic stewardship is an integral part of healthcare quality improvement, as it ensures that patients receive optimal effective treatment for infections and that the adverse effects are minimized. Public health involvement in implementing antibiotic stewardship activities is important for assisting national and remote efforts to combat antibiotic resistance and improve antibiotic use.
