What are the principles of Antibiotic (Antimicrobial) Stewardship?

From the Guidelines

Antibiotic stewardship principles should prioritize optimizing antibiotic use to improve patient outcomes while minimizing resistance and adverse effects, as recommended by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America 1. The core principles of antibiotic stewardship include:

• Prescribing antibiotics only when truly necessary
• Selecting the appropriate drug for the specific infection
• Using the correct dose and duration
• Regularly reassessing therapy When prescribing, it is essential to choose narrow-spectrum antibiotics when possible, such as penicillin for streptococcal pharyngitis, rather than broader agents like azithromycin, and reserve broad-spectrum antibiotics, like carbapenems and newer cephalosporins, for severe or resistant infections 1. Implementing the "Start smart, then focus" approach by obtaining cultures before starting antibiotics and then de-escalating therapy based on results is also crucial, as well as documenting indications, planned duration, and review dates for all antibiotic prescriptions 1. The three basic requirements of an Antimicrobial Stewardship program are: a multidisciplinary antimicrobial stewardship team, a microbiological report on bacterial resistance, and a report on antibiotic consumption 1. Regular antibiotic "time-outs" at 48-72 hours allow for therapy reassessment based on clinical response and culture results, and duration should be as short as clinically appropriate, with many infections requiring only 5-7 days rather than traditional 10-14 day courses. These practices help preserve antibiotic effectiveness by reducing selective pressure that drives resistance, decrease medication costs, and minimize patient exposure to potential adverse effects like Clostridioides difficile infections, allergic reactions, and organ toxicities 1.

From the FDA Drug Label

To reduce the development of drug-resistant bacteria and maintain the effectiveness of Piperacillin and Tazobactam for Injection and other antibacterial drugs, piperacillin and tazobactam should be used only to treat or prevent infections that are proven or strongly suspected to be caused by bacteria When culture and susceptibility information are available, they should be considered in selecting or modifying antibacterial therapy. In the absence of such data, local epidemiology and susceptibility patterns may contribute to the empiric selection of therapy. Patients should be counseled that antibacterial drugs including piperacillin and tazobactam for injection should only be used to treat bacterial infections. They do not treat viral infections (e.g., the common cold). When piperacillin and tazobactam for injection is prescribed to treat a bacterial infection, patients should be told that although it is common to feel better early in the course of therapy, the medication should be taken exactly as directed Skipping doses or not completing the full course of therapy may (1) decrease the effectiveness of the immediate treatment and (2) increase the likelihood that bacteria will develop resistance and will not be treatable by piperacillin and tazobactam for injection or other antibacterial drugs in the future

The antibiotic stewardship principles for piperacillin-tazobactam include:

• Using the drug only to treat or prevent infections proven or strongly suspected to be caused by bacteria
• Considering culture and susceptibility information when available to guide therapy
• Using local epidemiology and susceptibility patterns to inform empiric selection of therapy when culture data are not available
• Counseling patients to only use the drug for bacterial infections and to complete the full course of therapy as directed to minimize the development of resistance 2 2

From the Research

Antibiotic Stewardship Principles

• The main goal of antibiotic stewardship is to optimize antibiotic use, improve patient outcomes, and reduce the emergence of antibiotic resistance and adverse drug effects 3
• Key elements of antibiotic stewardship include leadership commitment, accountability, pharmacy expertise, action, tracking, reporting, and education 3

Effective Antibiotic Treatments

• Piperacillin/tazobactam has been shown to be more effective than ceftriaxone plus clindamycin in the treatment of early, non-ventilator, hospital-acquired pneumonia (NV-HAP) 4
• Ceftriaxone is a useful option in the treatment of aspiration pneumonia and is not inferior to broad-spectrum antibiotic treatment 5
• Levofloxacin has been shown to be as effective as ceftriaxone plus azithromycin combination in the treatment of community-acquired pneumonia (CAP) in hospitalized patients 6
• A network meta-analysis found that ceftaroline and piperacillin have the highest probability of being the best empiric antibiotics for cure rate, while ceftriaxone plus levofloxacin, ertapenem, and amikacin plus clarithromycin have the highest probability of being the best for mortality rate 7

Considerations for Antibiotic Use

• The use of broad-spectrum antibiotics should be optimized to reduce the risk of antibiotic resistance and adverse drug effects 4, 5, 3
• The choice of antibiotic should be based on the specific needs of the patient and the suspected or confirmed cause of the infection 4, 5, 6, 7
• Antibiotic stewardship programs should be implemented to promote the responsible use of antibiotics and improve patient outcomes 3