Antimicrobial Stewardship

Stacy Huang

EPID 680 Hospital Epidemiology I

3-15-19

“This essay is submitted to meet partially Competency #5 of the Hospital and Molecular

Epidemiology Track of Epidemiology MPH Program, University of Michigan, School of Public

Health".
1.) Background and Significance

The use of antimicrobials to treat infections and diseases dates back to ancient

civilizations and has continued ever since (10). Among the most widely used antimicrobials are

antibiotics. Alexander Fleming discovered the first antibiotic, Penicillin, in 1928 when he

observed the fungus Penicillium notatum kill a culture of Staphylococcus aureus by producing a

small substance (1). This event marked the beginning of the modern “antibiotic era”. However, it

was not until the early 1940s that the true potential of penicillin was acknowledged when it was

used to treat burn wound infections during World War II (1). Afterwards, the application of

antibiotics quickly became popular, which has led to the increasing use and dependence on

antibiotics up to the present day. Antibiotics have been proven to reduce illness and death from

infectious diseases. However, 20-50% of all antibiotics prescribed in U.S. hospitals are either

unnecessary or inappropriate (2). The widespread use and misuse of antibiotics have resulted

in the emergence of antibiotic resistant organisms. Antibiotic resistance poses a major and

growing threat to public health. Over 2 million people in the United States are infected with

antibiotic resistant organisms, causing more than 23, 000 deaths annually (2). Antibiotic

resistance is especially a concern in hospitals where antibiotic use is high. In response to this

problem, hospitals have implemented policies and programs to control and monitor the use of

antibiotics.

Overuse of antibiotics was identified as a problem since the 1950s when it was linked to

the emergence of resistance (4). During this time, physicians were educated on the importance

of using antibiotics more judiciously to prevent resistance from worsening. For decades

however, physicians inappropriately prescribed antibiotics despite what they were told (4). In the

1970s, hospitals adopted programs to limit antibiotic use, however, they were unsuccessful due

to lack of authority to execute regulations. From these efforts to reduce antibiotic use, in the

2000s, today’s antimicrobial stewardship programs (ASPs) were developed, and they have

become a requirement for hospitals (4).

2. Concept, Principles and Activities

Antimicrobial stewardship programs are organizational systems with a set of coordinated

strategies that aim to control and monitor use of antimicrobials, including antibiotics, in

healthcare settings, thus improving the use of antibiotics to optimize clinical outcomes (8).

Antimicrobial stewardship has a set of principles that provide a framework for achieving its

goals. One principle of antimicrobial stewardship is education. Education is an important

element designed to influence prescribing behavior and can enhance expertise (5). There are

educational resources for clinicians and patients such as staff conferences, instructional

materials, and peer-reviewed guidelines for management of particular infections. Another

principle of ASPs is formulary restriction, which focusses on evaluating antibiotic use and drug

costs by controlling formulary contents. This involves analysis of susceptibility and resistance

patterns in certain geographic areas to decide which drugs should be included or removed from

the formulary (5, 6). Dose optimization is also an ASP principle. Dose of the antimicrobial is

important when treating an infection because a dose that is too low may not be effective and a

dose that is too high may have adverse effects. Optimizing antimicrobial dosing based on

individual patient characteristics, causative organism, site of infection, and pharmacokinetic and

pharmacodynamic characteristics of the antimicrobial is a critical component of antimicrobial

stewardship (3). This ensures that antimicrobials are used appropriately based on the needs

and characterizations of the patient. These are just some of the strategies ASPs use in efforts to

improve antibiotic use. ASPs implement a combination of interventions to achieve the goals of

the programs.

3.) Application and Impact

Many studies have been conducted to monitor the effectiveness of ASPs and evaluate

the impact of ASPs. Timbrook et al. (2016) examined the impact of an ASP on antimicrobial

use, bacterial susceptibilities and financial expenditures at an academic medical center. The

ASP in this hospital focused on improving the use of antimicrobials in adult patients through
formulary restriction and dose optimization interventions. The program also involved preparation

and implementation of empiric therapy guidelines, clinical pathways, and clinical education (9).

The researchers conducted quasi-experimental, before and after ASP implementation,

retrospective analyses to characterize the impact of this program. They found that ASP

interventions were associated with an observed reduction in stewardship-focused antibiotic use

(9). There were significant changes in susceptibilities of some bacteria, but this was not

representative of changes in antibiotic use. Decreases in antimicrobial expenditures were also

observed. The observed outcomes were temporally associated with shifts in antimicrobial

selection through implementation of ASP initiatives (9). This shows that ASPs are beneficial in

the control of antibiotic use. Another study was conducted by Ruiz et al. where they examined

an ASP in a 24-bed medical ICU in a tertiary hospital. They utilized a prospective interventional,

before and after study to evaluate the impact of the program on antimicrobial consumption,

antimicrobial-related costs, multi-drug resistant microorganisms (MDRM) prevalence,

nosocomial infections incidence, ICU length of stay, and ICU mortality rates (7). They found that

total antimicrobial DDD/100 patient-days consumption decreased from 380.6 to 295.2 (-22.4%;

p=0.037). There was also a decrease in in the prescription of penicillins plus b-lactamase

inhibitors. Antimicrobial spending also decreased by by €119,636 (7). MDRM isolation and

nosocomial infections per 100 patient-days did not change after the intervention period. There

were no changes in length of stay or mortality rate. Overall, the ICU ASP significantly reduced

antimicrobial use without influencing inpatient mortality or length of stay (7). The results from

this study also suggest that ASPs are advantageous and should be implemented to reduce

antibiotic use.

4.) Summary

Antimicrobial stewardship is an important strategy in combating antimicrobial resistance.

Well-established ASPs can improve antimicrobial use and reduce drug expenditures. Studies

have demonstrated the positive impact and potential of ASPs. However, further high-quality
studies are needed to understand the issues and challenges facing ASPs. Additionally, studies

are necessary to understand how the programs can be structured to best manage the use of

antimicrobials since not every ASP utilize the same strategies. There is high prevalence of

multi-drug resistant organisms and antimicrobial resistance is a serious threat worldwide.

Therefore, appropriate antimicrobial stewardship that focuses on optimization of antimicrobial

use is critical for preventing emerging resistance and the dissemination of resistant

microorganisms.
 References

1. Aminov, R. I. (2010). A Brief History of the Antibiotic Era: Lessons Learned and Challenges

for the Future. Frontiers in Microbiology,1.

2. CDC. Core Elements of Hospital Antibiotic Stewardship Programs. Atlanta, GA: US

Department of Health and Human Services, CDC; 2014. Available at

http://www.cdc.gov/getsmart/healthcare/ implementation/core-elements.html.

3. Dellit, T. H. (2007). Summary of the Infectious Diseases Society of America and the Society

for Healthcare Epidemiology of America Guidelines for Developing an Institutional Program

to Enhance Antimicrobial Stewardship. Infectious Diseases in Clinical Practice,15(4), 263-

264.

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Principles and Practice,15-23.

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9. Timbrook, T. T., Hurst, J. M., & Bosso, J. A. (2016). Impact of an Antimicrobial Stewardship

Program on Antimicrobial Utilization, Bacterial Susceptibilities, and Financial Expenditures at

an Academic Medical Center. Hospital pharmacy, 51(9), 703-711.

10. Ventola C. L. (2015). The antibiotic resistance crisis: part 1: causes and threats. P & T: a

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