What are the contents of antimicrobial (antibiotic) stewardship?

Contents of Antimicrobial Stewardship Programs

Antimicrobial stewardship refers to interventions and programs that aim to optimize antimicrobial use, achieving effective treatment while minimizing antimicrobial-associated harms including resistance. 1

Core Components of Antimicrobial Stewardship

Multidisciplinary Team Structure

• Collaboration between clinicians, pharmacists, microbiologists, infectious disease specialists, and primary care providers is essential for successful antimicrobial stewardship programs 1, 2
• Dedicated representation from all clinical areas (including ED clinicians) on antimicrobial stewardship committees ensures comprehensive implementation 1, 2
• Clinical pharmacists with infectious disease expertise play a critical role in addressing appropriate antibiotic use 1, 2

Education and Guidelines

• Active educational programs including seminars and roundtable discussions to promote clinician engagement and dialogue 1, 2
• Development of facility-specific clinical practice guidelines based on local resistance patterns 1, 2
• Educational messaging tailored to specific practice patterns and challenges of different clinical environments 1, 2
• Inclusion of infectious disease topics in departmental conferences and inter-specialty meetings 1, 2

Diagnostic Stewardship

• Implementation of biomarker testing (e.g., procalcitonin) and rapid pathogen identification to improve antibiotic prescribing decisions 2
• Selective use of blood cultures in patients with suspected infections, particularly when signs of sepsis are absent 2
• Rapid diagnostic testing to distinguish between viral and bacterial pathogens, reducing unnecessary antibiotic use 2, 3

Intervention Strategies

• Prospective audit and feedback on antimicrobial prescriptions with real-time intervention 2, 4
• Watchful waiting or delayed antibiotic prescribing for select patients with less severe infections 2
• Structured culture follow-up programs for patients discharged with pending cultures 2
• Shortening duration of therapy according to current guidelines to reduce selective pressure for resistant bacteria 2, 3
• Dose optimization based on patient characteristics, pathogen, infection site, and pharmacokinetic/pharmacodynamic properties 2, 3

Monitoring and Measurement

• Tracking antimicrobial utilization patterns and resistance trends 1, 2
• Monitoring appropriateness of antibiotic therapy choice, rehospitalization rates, and time to culture review 2, 5
• Evaluation of clinical outcomes including mortality, length of stay, and adverse events 4
• Assessment of cost-effectiveness and resource utilization 4, 5

Implementation Considerations

Setting-Specific Adaptations

• Emergency departments require special consideration due to rapid patient turnover, need for quick decision-making, and high provider variability 1, 2
• Inpatient settings benefit from more intensive monitoring and intervention strategies 4
• Outpatient settings require focus on appropriate prescribing for common conditions like respiratory infections 3

Barriers to Implementation

• Provider concerns about medical liability and failure to diagnose/treat 1
• Patient satisfaction pressures and expectations for antibiotics 1
• Resource constraints and operational efficiency concerns 1
• Tension between appropriate broad-spectrum antibiotic use for life-threatening infections and stewardship goals 1, 2

Technology Support

• Computer-assisted decision support systems to identify opportunities for intervention 4
• Electronic health record integration to facilitate real-time feedback 4
• Automated alerts for inappropriate antimicrobial use 6, 4

Outcomes and Benefits

• Reduced rates of antimicrobial resistance 6
• Decreased incidence of Clostridioides difficile infections 6
• Shortened hospital length of stay 4
• Lower healthcare costs related to antimicrobial use 4, 5
• Improved appropriateness of antimicrobial prescribing 4, 7

Pitfalls to Avoid

• Implementing education alone without complementary strategies, as this is insufficient for sustained practice change 1, 2
• Failing to adapt guidelines to local resistance patterns and patient populations 1, 2
• Neglecting to include frontline clinicians in program development and implementation 2, 7
• Overlooking the importance of diagnostic stewardship alongside antimicrobial stewardship 2, 3
• Implementing restrictive policies without educational support, which may lead to clinician resistance 1, 7