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Antibiotic stewardship programs: Potential and pitfalls
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The latest recommendations from the Infectious Diseases Society of America and Society for Healthcare Epidemiology of America on antimicrobial stewardship programs, or ASPs, are a plea for hospitals to support their ASPs, and their recommendations consist of more than a dozen suggestions. Clearly, all hospitals and practitioners support optimal antibiotic use. The problem is to recognize that each hospital is different in terms of infectious disease and infection control expertise, antibiotic use habits, antibiotic resistance patterns and Clostridium difficile incidence. Components of some ASPs may have little or no relevance for hospitals of different sizes, demographics and geographic location. The great value of the prospective audit is to tailor ASPs to the needs of the hospital. “One size does not fit all,” and most importantly, “the devil is in the details.” There are some reasonable ASP objectives, and there are extremely difficult ASP problems that often defy the best-intended efforts to improve or solve.
Among important areas that are amenable to improvement, independent of hospital factors (vide supra), are needless antibiotic therapy of viral infections. The most important advance in rapid viral diagnostics has been the widespread use of multiplex PCR to diagnose respiratory viral infections. Even with PCR, many admitted adults are unnecessarily treated with antibiotics for presumed bacterial coinfection (excluding influenza), which is rare. A decrease in unnecessary antibiotic therapy for respiratory viral infections is not only cost-effective, but may decrease adverse effects of unneeded antibiotics.
The “low hanging fruit” of ASPs are in the areas of duration of antibiotic therapy, IV-to-PO switch (or oral therapy alone), and optimization of antibiotic dosing based on the antibiotic’s pharmacokinetic/pharmacodynamic (PK/PD) characteristics. Interventions in these areas improve patient care (reduced length of stay with reduced adverse effects). When it comes to empiric therapy for community-acquired pneumonia, well-chosen monotherapy is preferred (eg, quinolone or doxycycline), rather than relying on de-escalation if the diagnosis remains uncertain, or “double-drug” therapy for typical and atypical pathogen coverage.
Source: Fleming-Dutra KE, et al. JAMA. 2016;doi:10.1001/jama.2016.4151.
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Education is the key component of PK/PD optimization of antibiotic dosing because suboptimal antibiotic therapy may predispose to therapeutic failure or, with subtherapeutic doses, to antibiotic resistance. This ASP intervention costs the hospital nothing.
In contrast, the most difficult problems in any ASP are antibiotic resistance and C. difficile. Antibiotic resistance is best controlled by a formulary that restricts “high-resistance potential” antibiotics. A nonselective decrease in antibiotic use (ie, “antibiotic tonnage,” referring to total antibiotic use), or of certain antibiotic classes (eg, third-generation cephalosporins), will have no effect on hospitalwide resistance. Conversely, restriction of the “high-resistance potential” members of the third-generation cephalosporin class (eg, ceftazidime) may be very effective. To restrict the other third-generation cephalosporins that are “low-resistance potential” antibiotics (eg, ceftriaxone) makes little sense and will not have the desired effect.
Lastly, C. difficile is a worthy but difficult ASP target. Antibiotic intervention alone cannot be expected to have a major effect on C. difficile incidence. Once again, nonselective restriction (ie, decreasing “antibiotic tonnage”) per se will not be effective. Restricting clindamycin and beta-lactams are effective C. difficile control measures, but the C. difficile problem is not just related to antibiotics. C. difficile diarrhea has been associated with cancer chemotherapy, proton pump inhibitors, laxatives/stool softeners, some antidepressants, and person-to-person/fomite-to-person spread. Besides antibiotics, control of C. difficile depends on handwashing and effective infection control measures.
Evidence to support many ASP interventions is conflicting or not convincing, which may be due to the wide variety of different hospitals included in many of these studies. In conclusion, while all hospitals need an ASP, just having an ASP does not make it good nor effective. Aspects of ASPs should be tailored to each hospital’s particular antibiotic-related problems and must not be just a checklist of ASP interventions. Prospective audit remains the best way to assess ASP effectiveness in each hospital.
- References:
- Akpan MR, et al. Antibiotics. 2016;doi:10.3390/antibiotics5010005.
- Barlam TF, et al. Clin Infect Dis. 2016;doi:10.1093/cid/ciw118.
- Coulter S, et al. Int J Antimicrob Agents. 2015;doi:10.1016/j.ijantimicag.2015.04.007.
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- Schuts EC, et al. Lancet Infect Dis. 2016;doi:10.1016/S1473-3099(16)00065-7.
- For more information:
- Burke A. Cunha, MD, MACP, is an Infectious Disease News Editorial Board member, chief of the infectious disease division at Winthrop-University Hospital, Mineola, N.Y., and professor of medicine at SUNY School of Medicine, Stony Brook, N.Y.
Disclosure: Cunha reports no relevant financial disclosures.