What are the principles of antibiotic stewardship for a patient with a suspected bacterial infection?

Antibiotic Stewardship Core Principles

Antibiotic stewardship fundamentally aims to optimize antibiotic use to improve patient outcomes—specifically reducing morbidity and mortality—while minimizing adverse events, preventing antimicrobial resistance, and reducing healthcare costs. 1, 2

Primary Goal Framework

The overarching objective is to improve clinical outcomes while simultaneously minimizing unintended consequences including adverse drug events, Clostridium difficile infections, selection of resistant organisms, and unnecessary healthcare expenditures. 2, 3 This requires balancing individual patient benefit against the broader public health threat of antimicrobial resistance. 1

The "5 D's" of Optimal Prescribing

Every antibiotic prescription must address five critical parameters: 2

• Right Diagnosis: Document objective clinical evidence supporting bacterial (not viral) infection before initiating therapy 1
• Right Drug: Use only agents to which the causative organism is susceptible, based on local resistance patterns 4, 1
• Right Dose: Optimize dosing parameters including amount, interval, and formulation to maximize efficacy 4
• Right Duration: Use the shortest effective treatment course 4
• Right De-escalation: Narrow spectrum or discontinue antibiotics based on culture results and clinical response 2

Essential Pre-Treatment Actions

Before prescribing antibiotics, clinicians must: 1, 3

• Obtain appropriate cultures before antibiotic administration, particularly in critically ill patients
• Measure objective sepsis parameters to document infection severity
• Implement rapid diagnostic testing to distinguish viral from bacterial pathogens, thereby reducing unnecessary antibiotic use
• Consider watchful waiting or delayed prescribing for less severe infections where observation is clinically safe 1

Core Implementation Strategies (Highest Quality Evidence)

Two primary intervention strategies have the strongest evidence base: 2, 3

1. Prospective Audit and Feedback (PAF)

• Review antibiotic prescriptions after initiation with real-time intervention to optimize therapy 3
• Allows more clinical data availability for recommendations, enhancing prescriber acceptance 3
• Demonstrated 22% reduction in antibiotic use and decreased C. difficile infections over 7-year periods without increasing mortality 3
• Maintains prescriber autonomy while building collegial relationships 3

2. Preauthorization/Formulary Restriction

• Requires real-time approval before administering restricted antibiotics 3
• Provides direct control over antibiotic use, reducing initiation of inappropriate therapy 3
• Optimizes empiric choices and decreases antibiotic costs 3

Common Pitfall: Never implement restrictive policies without concurrent educational support, as this generates clinician resistance and workarounds. 1

Required Leadership and Infrastructure

Effective stewardship programs require: 1, 2, 3

• Leadership by infectious disease physicians with additional stewardship training
• Partnership with clinical pharmacists possessing infectious disease expertise
• Facility-specific clinical practice guidelines based on local (not just national) resistance patterns—this is critical as national guidelines may not reflect your institution's microbiology 1
• 24/7 access to stewardship consultation, particularly in emergency departments 1

Continuous Monitoring Requirements

Programs must track: 1, 3

• Antimicrobial utilization patterns using Days of Therapy (DOTs) per 1,000 patient-days as the preferred metric 3
• Local and regional resistance trends to inform formulary decisions 1
• Appropriateness of antibiotic therapy choices through guideline compliance measurement 3
• Secondary outcomes including rehospitalization rates and time to culture review 3

Institutional Infrastructure Mandates

Healthcare executives must: 4

• Establish antibiotic stewardship as a strategic goal and clinical governance objective 4
• Adequately resource infection control, education, and audit capabilities 4
• Create and empower a multidisciplinary antibiotic team to control injudicious use 4
• Set minimum clinical standards for infection control and prescribing, with consequences for non-compliance 4

Operational Components

Implement these specific measures: 4

• Automatic stop dates for antibiotic orders
• Antibiotic prescription forms requiring justification
• Centralized intravenous administration service
• Selective reporting of sensitivities—only report formulary agents routinely to avoid implying sanction for non-formulary antibiotics 4
• Electronic delivery of laboratory results to minimize transport and reporting delays 4
• Ward visits and personal contact between laboratory personnel and prescribers 4

Education Across All Levels

Comprehensive education is essential but often neglected: 4, 5

• Target patients, healthcare professionals, and students to reduce inappropriate prescribing pressure 4
• Focus undergraduate medical curricula on microbiology, infectious diseases, and clinical pharmacology with emphasis on prudent prescribing principles 5
• Incorporate antibiotic stewardship into continuous professional development and clinical governance programs for all prescribers 4

Common Pitfall: Avoid relying solely on national guidelines without adaptation to local resistance patterns and patient populations. 1