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antimicrobial stewardship

also see antibiotic prescribing practices Management: - judicious use of antimicrobial agents to a) diminish emergence of antimicrobial-resistant organisms b) reduce medical costs c) minimized adverse drug reactions - use narrow spectrum antibiotic a) ampicillin considered narrow spectrum b) ciprofloxcin is considered broad spectrum - specific recommendations [10] - preauthorization or prospective audit & feedback - pharmacokinetic monitoring & adjustment programs for aminoglycosides & vancomycin - programs to increase appropriate use of oral over IV antibiotics - rapid viral testing of respiratory specimens - use of days of therapy to monitor antibiotic use - other recommendations (MKSAP) [2,3] - simplify unnecessary antibiotic combinations - avoid double anaerobic coverage - convert intravenous agents to oral agents - streamline de-escalation - minimize therapy duration - prompts about antibiotic stewardship safely limit extended-spectrum antibiotics in patients with pneumonia or urinary tract infections [31] - use Plan-Do-Study-Act cycle for interventions (MKSAP) [2] Notes: - 28% of outpatient broad spectrum antibiotic prescriptions deemed unnecessary [4] - 30% of outpatient antibiotic prescriptions deemed unnecessary [11] - antibiotics for hospitalized patients is sometimes unnecessary & results in no benefit but potential harm [16] - excessive antibiotic use in nursing homes is associated with an increased risk of C difficile colitis among fellow nursing home residents not receiving antibiotics [6] - a multicomponent intervention promoting goal-directed care for suspected urinary tract infections & lower respiratory tract infections did not reduce antimicrobial use among nursing home residents with advanced dementia [28] - ~ 1/2 of organisms causing surgical site infections & ~ 1/4 causing infections after chemotherapy are resistant to recommended prophylaxis regimens [7] - antifungal use in US hospitals declined significantly from 2006 to 2012, but still often unnecessarily prescribed [18] - a U.S. federal educational project helped hospital staff reduce quinolone use & C difficile infections by 20% [27] - peer comparison of prescribing practice & EHR-prompted justification for antibiotic use for inclusion in the medical record reduce inappropriate antimicrobial prescribing practices [8] - physician-designed interventions may improve appropriateness, but not quantity of antibiotics prescribed [14] - older, busier, & foreign-trained practitioners more likely to overprescribe antibiotics [13] - 5% of population may use non-prescribed antibiotics each year [12] - antibiotic stewardship programs effective in lowering incidence of drug-resistant bacterial infections & colonization in hospitals [15] - palliative care consultation for cancer patients at the end-of-life may reduce inappropriate antibiotic prescribing (also see antimicrobial stewardship) [29] - inappropriate antibiotic prescribing is common in ambulatory care settings, particularly urgent care [17] - urgent care: 46% - emergency department: 25% - medical offices: 17% - retail clinics: 14%

Related

antibiotic prescribing practices; antibiotic overuse; outpatient parenteral antibiotics antibiotic resistance infection control

References

  1. Standiford HC et al. Antimicrobial stewardship at a large tertiary care academic medical center: Cost analysis before, during, and after a 7-year program. Infect Control Hosp Epidemiol 2012 Apr; 33:338 PMID: 22418628
  2. Medical Knowledge Self Assessment Program (MKSAP) 16, 17, 19. American College of Physicians, Philadelphia 2012, 2015, 2021
  3. Dellit TH, Owens RC, McGowan JE et al Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clin Infect Dis. 2007 Jan 15;44(2):159-77. Epub 2006 Dec 13. PMID: 17173212
  4. Shapiro DJ et al. Antibiotic prescribing for adults in ambulatory care in the USA, 2007-09 J Antimicrob Chemother 2013 Jul 25 PMID: 23887867 http://jac.oxfordjournals.org/content/early/2013/07/24/jac.dkt301
  5. Centers for Disease Control and Prevention (CDC) Making Health Care Safer. Antibiotic Rx in Hospitals: Proceed with Caution. March 2014 http://www.cdc.gov/vitalsigns/antibiotic-prescribing-practices/index.html
  6. Daneman N et al. Variability in antibiotic use across nursing homes and the risk of antibiotic-related adverse outcomes for individual residents. JAMA Intern Med 2015 Jun 29 PMID: 26121537 http://archinte.jamanetwork.com/article.aspx?articleid=2337257
  7. Teillant A, Gandra S, Barter D, Morgan DJ, Laxminarayan R. Potential burden of antibiotic resistance on surgery and cancer chemotherapy antibiotic prophylaxis in the USA: a literature review and modelling study. Lancet Infectious Diseases. 15 October 2015 PMID: 26482597 http://www.thelancet.com/journals/lancetid/article/PIIS1473-3099%2815%2900270-4/abstract
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  9. Society for Healthcare Epidemiology of America; Infectious Diseases Society of America; Pediatric Infectious Diseases Society. Policy statement on antimicrobial stewardship by the Society for Healthcare Epidemiology of America (SHEA), the Infectious Diseases Society of America (IDSA), and the Pediatric Infectious Diseases Society (PIDS). Infect Control Hosp Epidemiol. 2012 Apr;33(4):322-7 PMID: 22418625
  10. Young K, Sadoughi S, Saitz R ID Experts Offer Guidelines for Antibiotic Stewardship Physician's First Watch, April 14, 2016 David G. Fairchild, MD, MPH, Editor-in-Chief Massachusetts Medical Society http://www.jwatch.org
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  12. Zoorob R, Grigoryan L, Nash S, Trautner BW. Nonprescription antimicrobial use in a primary care population in the United States. Antimicrob Agents Chemother 2016 Sep; 60:5527 PMID: 27401572 http://aac.asm.org/content/60/9/5527
  13. Silverman M et al. Antibiotic prescribing for nonbacterial acute upper respiratory infections in elderly persons. Ann Intern Med 2017 May 9; PMID: 28492914 - Jones BE, Samore MH. Antibiotic overuse: Clinicians are the solution. Ann Intern Med 2017 May 9 PMID: 28492844
  14. Sikkens JJ, van Agtmael MA et al. Behavioral approach to appropriate antimicrobial prescribing in hospitals: The Dutch Unique Method for Antimicrobial Stewardship (DUMAS) participatory intervention study. JAMA Intern Med 2017 May 1 PMID: 28459929
  15. Baur D, Gladstone BP, Burkert F et al Effect of antibiotic stewardship on the incidence of infection and colonisation with antibiotic-resistant bacteria and Clostridium difficile infection: a systematic review and meta-analysis. Lancet Infect Dis. 2017 Sep;17(9):990-1001 PMID: 28629876 http://www.thelancet.com/journals/laninf/article/PIIS1473-3099(17)30325-0/fulltext - Goff DA, Medelson M Antibiotic stewardship hits a home run for patients. Lancet Infect Dis. 2017 Sep;17(9):892-893 PMID: 28629875 http://www.thelancet.com/journals/laninf/article/PIIS1473-3099(17)30344-4/fulltext
  16. Tamma PD, Avdic E, Li DX, Dzintars K, Cosgrove SE. Association of adverse events with antibiotic use in hospitalized patients. JAMA Intern Med 2017 Jun 12; PMID: 28604925
  17. Palms DL, Hicks LA, Bartoces M et al Comparison of Antibiotic Prescribing in Retail Clinics, Urgent Care Centers, Emergency Departments, and Traditional Ambulatory Care Settings in the United States. JAMA Intern Med. Published online July 16, 2018. PMID: 30014128 https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2687524 - Incze MA, Redberg RF, Katz MH. Overprescription in Urgent Care Clinics - The Fast and the Spurious. JAMA Intern Med. Published online July 16, 2018. PMID: 30014130 https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2687523
  18. Vallabhaneni S, Baggs J, Tsay S et al. Trends in antifungal use in US hospitals, 2006-2012 J Antimicrob Chemother 2018 Jul 25; Not indexed in PubMed https://academic.oup.com/jac/advance-article-abstract
  19. Pulia M, Redwood R, May L. Antimicrobial Stewardship in the Emergency Department. Emerg Med Clin North Am. 2018 Nov;36(4):853-872. Review. PMID: 30297009
  20. Dyar OJ, Huttner B, Schouten J et al What is antimicrobial stewardship? Clin Microbiol Infect. 2017 Nov;23(11):793-798. Review. PMID: 28882725 Free Article
  21. Naylor NR, Zhu N, Hulscher M Is antimicrobial stewardship cost-effective? A narrative review of the evidence. Clin Microbiol Infect. 2017 Nov;23(11):806-811. Review. PMID: 28642146 Free Article
  22. Foolad F, Nagel JL, Eschenauer G et al Disease-based antimicrobial stewardship: a review of active and passive approaches to patient management. J Antimicrob Chemother. 2017 Dec 1;72(12):3232-3244. Review. PMID: 29177489
  23. Sanchez GV, Fleming-Dutra KE, Roberts RM, Hicks LA. Core Elements of Outpatient Antibiotic Stewardship. MMWR Recomm Rep. 2016 Nov 11;65(6):1-12. PMID: 27832047
  24. Dobson EL, Klepser ME, Pogue JM et al SIDP Community Pharmacy Antimicrobial Stewardship Task Force. Outpatient antibiotic stewardship: Interventions and opportunities. J Am Pharm Assoc (2003). 2017 Jul - Aug;57(4):464-473. Review. PMID: 28526402
  25. Drekonja DM, Filice GA, Greer N et al Antimicrobial stewardship in outpatient settings: a systematic review. Infect Control Hosp Epidemiol. 2015 Feb;36(2):142-52. Review. PMID: 25632996
  26. Cosgrove SE, Hermsen ED, Rybak MJ et al Guidance for the knowledge and skills required for antimicrobial stewardship leaders. Infect Control Hosp Epidemiol. 2014 Dec;35(12):1444-51. PMID: 25419765
  27. Tamma PD et al. Association of a safety program for improving antibiotic use with antibiotic use and hospital-onset Clostridioides difficile infection rates among US hospitals. JAMA Netw Open 2021 Feb 1; 4:e210235 PMID: 33635327 Free article https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2776911
  28. Mitchell SL, D'Agata EMC, Hanson LC et al The Trial to Reduce Antimicrobial Use in Nursing Home Residents With Alzheimer Disease and Other Dementias (TRAIN-AD). A Cluster Randomized Clinical Trial. JAMA Intern Med. Published online July 12, 2021. PMID: 34251396 https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2782003
  29. Kim JH et al. The impact of palliative care consultation on reducing antibiotic overuse in hospitalized patients with terminal cancer at the end of life: A propensity score-weighting study. J Antimicrob Chemother 2022 Nov 25; dkac405; [e-pub]. PMID: 36424671 https://academic.oup.com/jac/advance-article-abstract/doi/10.1093/jac/dkac405/6845777
  30. Johnson MC, Hulgan T, Cooke RG, et al. Operationalising outpatient antimicrobial stewardship to reduce system-wide antibiotics for acute bronchitis. BMJ Open Qual. 2021;10. PMID: 34210668
  31. Gohil SK, Septimus E, Kleinman K et al. Stewardship prompts to improve antibiotic selection for pneumonia: The INSPIRE randomized clinical trial. JAMA 2024 Apr 19; [e-pub]. PMID: 38639729 https://jamanetwork.com/journals/jama/fullarticle/2817976 - Gohil SK, Septimus E, Kleinman K et al. Stewardship prompts to improve antibiotic selection for urinary tract infection: The INSPIRE randomized clinical trial. JAMA 2024 Apr 19; [e-pub]. PMID: 38639723 https://jamanetwork.com/journals/jama/fullarticle/2817975
  32. Centers for Disease Control and Prevention (CDC) The Core Elements of Antibiotic Stewardship for Nursing Homes. http://www.cdc.gov/longtermcare/prevention/antibiotic-stewardship.html
  33. Centers for Disease Control and Prevention (CDC) Checklist for core elements of a stewardship program. http://www.cdc.gov/getsmart/healthcare/pdfs/checklist.pdf