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IDSA, SHEA publish new recommendations for antibiotic stewardship programs
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The Infectious Diseases Society of America and Society for Healthcare Epidemiology of America have replaced their original guidelines for antibiotic stewardship programs with new evidence-based recommendations. The guidelines, published today in Clinical Infectious Diseases, include the most effective strategies promoting optimal use of antibiotics, including preauthorization of broad-spectrum antibiotics, prospective review after treatment initiation and the use of rapid diagnostic testing.
“Initially, antibiotic stewardship was more focused on cost savings, and physicians responded negatively to that, because they often felt it was best to give patients the newest, most expensive drug,” Tamar F. Barlam, MD, co-lead guidelines author and director of the antibiotic stewardship program at Boston Medical Center and associate professor of medicine at Boston University Medical School, said in a press release. “While these programs do save hospitals money, their most important benefit is that they improve patient outcomes and reduce the emergence of antibiotic resistance. When we say stewardship, we really mean stewardship, and increasingly, doctors are realizing it’s important and necessary.”
The National Action Plan for Combating Antibiotic-Resistant Bacteria, issued by the White House in March 2015, calls for the implementation of antibiotic stewardship programs (ASPs) in all acute care hospitals by 2020. In response, Barlam and co-lead guidelines author Sara E. Cosgrove, MD, MS, president-elect of SHEA, director of the ASP and associate hospital epidemiologist at The Johns Hopkins Hospital, assembled a panel of 20 additional experts including clinicians and investigators of internal medicine, emergency medicine, microbiology, critical care, surgery, epidemiology, pharmacy and adult and pediatric infectious disease specialties to develop guidelines for ASPs that can be widely implemented in ED, acute inpatient and long-term care settings. The panel performed a literature review and analysis of studies assessing components of ASPs that improve antibiotic dosing by reducing the use of broad-spectrum antibiotics, antibiotic resistance, adverse events, costs, lengths of hospital stay and mortality.
Tamar F. Barlam
After their review, the panel developed 28 recommendations.
“We designed the new guidelines with the goal of trying to be really practical and to give a pretty extensive menu of the different options for programs since hospitals have different amounts of resources and expertise,” Barlam told Infectious Disease News. “However, we really wanted to stress that a stewardship program does need to have some active intervention in antibiotic prescribing.”
The first recommendation and foundation for a comprehensive ASP is preauthorization of certain antibiotics, including those used to treat emerging drug-resistant bacterial infections, and/or a prospective review of treatment typically 2 or 3 days after initiation when the prescribing physician receives culture results and is able to determine whether the patient is rapidly improving or deteriorating, Barlam said.
“The former guidelines seemed to have a bias on prospective audit, but actually, many of the studies have shown preauthorization can work more effectively,” she said. “In an ideal world, you would do both. Ultimately, it comes down to what the site can really do in a consistent manner. Some sites just don’t have someone who can answer calls on a regular basis and you don’t want to delay an appropriate antibiotic therapy, so [preauthorization] might not be a great strategy for a site that doesn’t have any onsite expertise.”
Among other recommendations, the panel advises health care facilities to:
- avoid relying solely on passive educational activities for ASPs such as lectures or pamphlets;
- implement multifaceted, syndrome-specific interventions vs. improving treatment of all infections simultaneously;
- reduce prescribing antibiotics associated with high risk for Clostridium difficile infections such as clindamycin and/or broad-spectrum antibiotics, including cephalosporins and fluoroquinolones;
- encourage prescribers to routinely review antibiotic regimens;
- employ computerized clinical decision support systems, if possible, that provide clinicians with treatment recommendations when prescribing antibiotics;
- implement pharmacokinetic monitoring for aminoglycosides and vancomycin;
- use alternative dosing strategies vs. standard dosing for broad-spectrum beta-lactams;
- increase appropriate use of oral antibiotics as initial treatment and switch from IV to oral therapy earlier;
- reduce therapy to the shortest effective duration;
- use rapid viral testing for respiratory viruses;
- use rapid diagnostic testing in addition to routine culture on blood specimens;
- incorporate nonculture-based fungal markers to optimize treatment in patients with hematologic malignancy who are at risk for invasive fungal disease;
- monitor antibiotic use by measuring days of therapy (DOTs) vs. defined daily dose (DDD); and
- measure antibiotic costs based on prescriptions or administrations rather than purchasing data.
The authors highlighted the need for each health care facility to personalize its ASP based on clinical needs and available resources, and also emphasized the importance of physician and pharmacist leadership and infectious disease expertise.
“We want hospital administrators to understand the importance of giving antibiotic stewardship their full support to ensure its success,” Cosgrove, who also is associate professor of medicine and epidemiology at Johns Hopkins University, said in the release. “Distributing a few brochures or holding grand rounds won’t do it. It’s vital that antibiotic stewardship be integrated into the hospital’s culture and that infectious disease specialists guide strategies that have been shown to work.”
The authors concluded that the new guidelines identify core interventions for all ASPs; however, more research is needed to investigate how to achieve large-scale implementation.
“Every health care facility is able to perform stewardship, and institution of an ASP is attainable and of great importance to public health,” they wrote. – by Stephanie Viguers
Disclosures: Barlam reports no relevant financial disclosures. Cosgrove reports receiving grants from Pfizer Grants for Learning and Change, and personal fees from Novartis outside the submitted work. Please see the guidelines for a full list of all other authors’ relevant financial disclosures.
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