Friday, March 16, 2018

Antimicrobial Stewardship

The first antimicrobial stewardship programs were introduced in hospitals more than 30 years ago to address inappropriate antibiotic prescribing and increasing antibiotic resistance. Since then a large body of evidence on the effectiveness and safety of this approach has accumulated.

The purpose of antimicrobial stewardship is to promote the prudent use of antibiotics in order to optimize patient outcomes, while at the same time minimizing the probability of adverse effects, including toxicity and the selection of pathogenic organisms, and the emergence and spread of antibiotic resistance.

The previous Cochrane Review demonstrated that interventions to reduce excessive antibiotic prescribing were successful, with persuasive and restrictive interventions being equally effective in reducing prescribing after six months. The recent update demonstrates that enabling and restrictive interventions are associated with a 15% increase in compliance with desired practice, a 1.95-day decrease in duration of antibiotic treatment, and a 1.12-day decrease in inpatient length of stay, without compromising patient safety.

Initiatives for implementing or strengthening antimicrobial stewardship were primarily developed as a response to increasing antibiotic resistance. Increasing antibiotic use results in increasing antibiotic resistance rates. But does improving antibiotic prescribing reverse antibiotic resistance rates? The updated Cochrane Review does not provide an answer; only 9% of the randomized controlled trials and 19% of the interrupted time series studies reported microbial outcome data. However, a reduction in the rate of Clostridium difficile infections was consistently demonstrated in the studies interventions.

Despite the extensive evidence base, antimicrobial stewardship programs are not a requirement in all hospitals. Antimicrobial resistance requires global action. This requires political commitment and resources, suggesting a role for continued advocacy by public health and specialist professionals and organizations. One significant characteristic of the evidence base is that 183 or the 221 studies in the updated Cochrane Review were performed in Europe or North American.

Antimicrobial stewardship is effective and safe. We need to ensure that it is implemented, and this Cochrane Review highlights two key delivery methods. Political commitment and adequate funding will be essential if antimicrobial stewardship is to be implemented in every healthcare setting.

My Take:
I believe reversing antibiotic resistance rates cannot be achieved through antimicrobial stewardship. The best we can hope for is keeping resistance rates stable or even reduce the rate of increase. Despite the best efforts there is no genetic drive to reduce resistance.

The C. difficile rate is a different story. It is an opportunistic infection from a commensal bacteria normally found in the gut, that takes over when antibiotic therapy kills other forms of bacteria (probiotic and otherwise) creating a void for the C. difficile to fill. Unfortunately, it is often life threatening and all too common in the hospital setting.

The Bottom Line:
It is unfortunate that persuasion is inadequate on its’ own and restrictive measures must be utilized for antimicrobial stewardship to be effective. Until all physicians understand and believe in this concept, the process will never expand to general practice. Hopefully, no super bug arises in the meantime to threaten the population as a whole. There have been a few incidences of such infections (like MRSA on steroids) that have been contained to date.

Source: Cochrane Library, February 9, 2017

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