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November 2008
Vol. 18 No. 11
Patient Care and Science
Antimicrobial Stewardship Programs, National Campaigns Curb Usage

Local antimicrobial stewardship programs and national public awareness campaigns both are effective means of reducing antibiotic use and resistance, according to speakers at the 48th Annual ICAAC/IDSA 46th Annual Meeting in Washington, D.C.

Antimicrobial stewardship — defined as a system of informatics, data collection, personnel, and policy/procedures that promote the optimal selection, dosing, and duration of therapy for antimicrobial agents — has been shown to limit the emergence and transmission of antimicrobial resistance when used in combination with infection control, said Christopher A. Ohl, MD, associate professor of medicine at Wake Forest University.

IDSA/SHEA Guidelines

In 2007, IDSA and SHEA published antimicrobial stewardship guidelines (Clin Infect Dis 2007; 44:159-77) to guide hospitals and other institutions in setting up comprehensive programs to cut antimicrobial use and lower resistance. “The key to a good program is to choose your name wisely and appeal to your base,” said Dr. Ohl. Program names containing the word “stewardship” appeal more than “control,” he said. Furthermore, it is imperative to demonstrate to the medical staff that the program is good for their patients. He suggested showing prescribers local antimicrobial-use data, which may surprise them.

Dr. Ohl described core elements of any successful program. They include a multidisciplinary team including an ID physician and a clinical pharmacist with ID training, as well as additional staff, including a clinical microbiologist, an information systems specialist, and an infection control professional. The team should develop a comprehensive program based on local antimicrobial use, local resistance patterns, and available resources.

The IDSA/SHEA guidelines recommend two core strategies that provide the foundation for an antimicrobial stewardship program. (These strategies are not mutually exclusive.) The two strategies are:

  • Prospective audit of antimicrobial use with direct interaction and feedback to the prescriber, performed by either an ID physician or a clinical pharmacist with ID training. The main disadvantage of this approach is that it is resource-intensive and prescribing changes are voluntary.
  • Formulary restriction and pre-authorization. Formulary restrictions can lead to immediate reductions in antimicrobial use and cost. The efficacy of pre-authorization is less clear, according to the guidelines, but may be useful in modulating antimicrobial use. Pre-authorizations are done by the ID physician or clinical pharmacist by pager or phone and usually result in a “mini-consult,” said Dr. Ohl. The disadvantage of this approach is that it could lead to inaccurate or misleading information from the prescriber or simply a switch to another antimicrobial agent that is not restricted or that does not require pre-authorization. Such approaches are also labor intensive and require nearly 24/7 support.

Supplemental interventions such as computerized order entry and clinical decision-making tools can be effective, added Dr. Ohl. One web-based clinical decision-support tool resulted in a $370,000 reduction in costs, an 11.6 percent reduction in doses, a 46 percent increase in user satisfaction, 40 percent fewer restricted antimicrobial-related phone calls, and an overall reduction in missed or delayed doses (Agwu et al. Clin Infect Dis 2008; 47:747-53).

National Campaigns

National antibiotic use campaigns are also an effective way to lower antimicrobial use and resistance. Herman Goossens, MD, of the University of Antwerp, Belgium, provided an overview of several European national public awareness campaigns, particularly Belgium’s program, which has been run every winter since 2000. Belgium spends 400,000 Euro every year on television ads, information booklets, posters, and Internet campaigns.

The program’s impact and outcome measures both indicate success. Nearly half of the public surveyed remember the antibiotics campaign (television had the biggest impact); they remember the main message was “we use them too much” (38 percent) and “take them only if needed (25 percent). After the campaign, two-thirds agreed to use fewer antibiotics in agreement with their general physician (GP) versus 64 percent before the campaign. An astounding 100 percent of GPs surveyed remembered the campaign three months after it ended.

Antimicrobial resistance in several classes is down in Belgium. Drug-resistant Streptococcus pyogenes (obtained from throat cultures) decreased from 18 percent in 2002 to 2 percent in 2007, according to data from the University of Antwerp. Outpatient antibiotic use has decreased as well.

Dr. Goossens also pointed to a huge cost savings across European programs. For every 1 Euro invested, 8 Euro were saved.

“Strong joint public health, scientific, and political leadership in Europe results in the curbing of antibiotic use and resistance, both in community and hospitals, in an increasing number of countries,” concluded Dr. Goossens.

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