What are antimicrobial (anti-microbial) stewardship interventions?

From the Guidelines

Antimicrobial stewardship interventions are crucial in optimizing antibiotic use, minimizing resistance, and reducing adverse effects, and should be implemented in all healthcare settings, including emergency departments, as recommended by the European Society of Clinical Microbiology and Infectious Diseases guidelines 1.

Key Interventions

• Implementing prospective audit and feedback systems where infectious disease specialists review antibiotic prescriptions and provide recommendations within 48-72 hours of initiation
• Establishing preauthorization requirements for broad-spectrum antibiotics like carbapenems, vancomycin, and newer agents like ceftazidime-avibactam
• Developing clinical pathways and guidelines tailored to local resistance patterns, such as recommending ceftriaxone 1g daily for community-acquired pneumonia instead of broader coverage when appropriate
• Implementing automatic stop orders that limit antibiotic duration to 7 days unless explicitly extended to prevent unnecessarily prolonged therapy
• Educating prescribers on proper antibiotic selection, dosing, and duration through targeted education programs
• Implementing rapid diagnostic testing to allow for earlier targeted therapy, and antibiotic "time-outs" at 48-72 hours to encourage reassessment of necessity and de-escalation opportunities, as supported by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines 1

Benefits of Antimicrobial Stewardship

• Reducing selective pressure that drives resistance
• Decreasing healthcare costs
• Minimizing adverse drug events
• Improving patient outcomes through more appropriate antimicrobial therapy that targets specific pathogens rather than providing unnecessarily broad coverage, which is a key goal of antimicrobial stewardship programs 1
• Optimizing clinical outcomes, including reduced morbidity, mortality, and improved quality of life, which is the primary goal of antimicrobial stewardship interventions 1

From the Research

Antimicrobial Stewardship Interventions

• Antimicrobial stewardship programs are a set of measures taken by an organization to optimize antimicrobial use, improve patient outcomes, reduce antimicrobial resistance and healthcare-associated infections, and save healthcare costs 2.
• The optimal use of antimicrobials is necessary to slow resistance development and improve patient outcomes, and antimicrobial stewardship is a bundle of interventions aimed at promoting the responsible use of antiinfectives 3.
• Antimicrobial stewardship interventions can improve the quality and quantity of antimicrobial prescribing in the ICU without compromising patient outcomes, and the de-escalation of empiric therapy according to microbiology results and the limitation of treatment duration are important steps to reduce resistance pressure 3.

Implementation of Antimicrobial Stewardship

• Healthcare facilities should have a defined antimicrobial stewardship policy in place that is available to all stakeholders, and the policy should be evidence-based, regularly updated, and communicated clearly both verbally and through visual means such as posters 2.
• All staff should be trained on the proper use of antimicrobials as well as how to report misuse, and antibiotic stewardship measures include educating and screening patients, monitoring, updating policies, limiting the use of high-risk medications, and developing and improving hand hygiene practices 2.
• Antimicrobial stewardship practices, principles, and interventions are critical steps towards containing and mitigating antimicrobial resistance, and evidence-based policies must guide the "One Health" approach, vaccination protocols, health professionals' education, and the public's awareness about antimicrobial resistance 4.

Effectiveness of Antimicrobial Stewardship Programs

• Antimicrobial stewardship strategies, such as prospective audit with intervention and feedback, clinical pathways, and dedicated multidisciplinary teams, have demonstrated improvements in antimicrobial use for community-acquired pneumonia without negatively affecting clinical outcomes 5.
• However, there is no solid evidence that antimicrobial stewardship programs are effective in reducing antibiotic resistance in hospital settings, and more studies with appropriate study designs, standardized antimicrobial stewardship program interventions targeting common microorganism-antibiotic pairs, and avoiding simultaneous implementation of infection control practices are needed 6.