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April 1, 2008
EIN: Antimicrobial Stewardship: Good Idea, Hard to Carry Out

The Emerging Infections Network (EIN) is a forum for infectious diseases consultants and public health officials to report information on clinical phenomena and epidemiological issues with public health significance. Any diagnostic or therapeutic recommendations and all opinions presented are those of the individual contributor. They do not necessarily represent the views of the EIN, the Infectious Diseases Society of America (EIN's sponsor) or the Centers for Disease Control and Prevention, which funds the EIN. The reader assumes all risks in using information.

While rising rates of antimicrobial resistance are driving many institutions to adopt antimicrobial stewardship programs, many are finding the principle difficult to put into practice. Some physicians from across the medical spectrum ignore recommendations to reduce unnecessary use of antimicrobials. In a recent discussion on the EIN listserve, members shared their suggestions for making this important concept work.

Some respondents discussed the need to develop institutional guidelines and “best practice” standards drawing from the IDSA/Society for Healthcare Epidemiology of America (SHEA) antimicrobial stewardship guidelines. One member is focusing on developing clinical practice guidelines designed specifically to focus on conditions involving high rates of antimicrobial usage such as Clostridium difficile-associated diarrhea, ventilator-associated pneumonia, catheter-associated infections, and surgical site infections.

To encourage buy-in, members recommend that “problem prescribers” should be encouraged to participate in formulating guidelines. “Our drafts will be discussed openly at ID conference, and we’ll give everyone a chance to weigh in and be heard,” the member said. “The end product won’t satisfy everyone, but it should be a step in the right direction.” Encouraging outliers to participate in pharmacy and therapeutics committees may also be helpful, another member suggested.

However, it may take a person-to-person approach to change individual habits. “Guidelines make sense. They are comforting and often right, but people need more,” one member said. “The reason an antimicrobial stewardship program is usually successful is because a physician will usually respond to another physician.”

A member suggested talking to problem prescribers in private about their prescription orders. “Chances are they haven't spent as much time thinking about the orders as you have.” Also, “Find out from them what they need and how you can work together,” the member said. Focus on the most active physicians. Others often follow their lead. Get to know your emergency department and surgical pre-op teams. These often are areas where improvements can be made, the member added.

If offering “carrots” doesn’t work, another member said, “The ‘stick’ approach is to track all of the patient harm, increased cost, longer length of stay, etc., which result from their poor clinical care. After several months you should have some ammunition to use with the administration in case there are a few stinkers who still refuse to play ball.”

IDSA and SHEA are working on materials to help institutions as they implement antimicrobial stewardship programs. Watch for more information in upcoming issues of IDSA News.

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