ANTIMICROBIAL DRUG STEWARDSHIP
The discovery of antimicrobials is one of the great advances in medicine and their use has substantially reduced morbidity and mortality worldwide. Unfortunately, with widespread antibiotic use we have witnessed the emergence of multidrug-resistant pathogens and reduced efficacy of many of our most powerful antimicrobials. In addition, we have also recognized many adverse effects of antimicrobials, most notably the rising rates of Clostridium difficile colitis. Further, the cost of medical care is greatly increased due to overuse of antibiotics and treating infections caused by resistant organisms. It is critical that health profession learners understand the key concepts behind antimicrobial stewardship at the time they learn about microbial pathogens and antimicrobials.
The worldwide problem of antibiotic resistance makes the need for antimicrobial stewardship evident. The Centers for Disease Control and Prevention estimates that in the United States over 2 million infections with multidrug-resistant pathogens occur each year leading to approximately 20,000 deaths. These pathogens include methicillin-resistant Staphylococcus aureus and extended-spectrum β-lactamase producing gram-negative rods (e.g., Escherichia coli and Klebsiella pneumoniae). Hospital–associated infections, many of which are caused by antibiotic-resistant bacteria, are estimated to cost billions of dollars each year.
The basic principles of good stewardship are threefold: (1) reduce inappropriate use of antibiotics, (2) encourage targeted treatment with narrow spectrum drugs, and (3) limit adverse effects (Table 10–1). Inappropriate antibiotic use can occur for many reasons, including the providers’ desire to adhere to patient’s wishes, even when it is not medically appropriate. The most common example of inappropriate antibiotic use is the prescribing of antibiotics for a viral respiratory tract infection.
TABLE 10–1Basic Principles of Antimicrobial Drug Stewardship |Favorite Table|Download (.pdf) TABLE 10–1 Basic Principles of Antimicrobial Drug Stewardship
|Current Problems in the Use of Antibiotics ||Role of Antimicrobial Drug Stewardship in Mitigating These Problems |
|Inappropriate use of antibiotics || |
Use antibiotics only when a microbiologic diagnosis indicates effectiveness
Empiric therapy should be tailored to the most likely pathogen(s)
Send appropriate cultures before starting antibiotics
|Overuse of broad-spectrum antibiotics || |
Use narrow-spectrum antibiotics whenever possible
Require approval for the use of advanced generation broad-spectrum antibiotics
|High rate of adverse effects || |
Stop antibiotics as soon as appropriate to reduce adverse effects, such as antibiotic-associated colitis caused by Clostridium difficile
Be aware of the effect of the patient’s renal function on the dose of antibiotic prescribed
Be aware of the patient’s hypersensitivity to specific antibiotics
Determine whether the patient’s declared hypersensitivity is correct and clinically significant
Warn patients regarding certain idiosyncratic drug reactions, such as photosensitization
The concept of targeted treatment refers to making a microbiologic diagnosis promptly and using the most specific antibiotic that has the best safety profile for the patient. If multiple broad-spectrum antibiotics are used as empiric therapy early in infection then switching to a narrow-spectrum antibiotic as soon as possible should be done. Cultures should be ...