What is antimicrobial stewardship? Dyar, O.J.; Huttner, B.; Schouten, J. ...
Clinical microbiology and infection,
11/2017, Letnik:
23, Številka:
11
Journal Article
Recenzirano
Odprti dostop
The use of the term ‘antimicrobial stewardship’ has grown exponentially in recent years, typically referring to programmes and interventions that aim to optimize antimicrobial use. Although ...antimicrobial stewardship originated within human healthcare, it is increasingly applied in broader contexts including animal health and One Health. As the use of the term ‘antimicrobial stewardship’ becomes more common, it is important to consider what antimicrobial stewardship is, as well as what it is not.
To review the emergence and evolution of the term ‘antimicrobial stewardship’.
We searched and reviewed existing literature and official documents, which mostly focused on antibiotics. We contacted the authors of the first publications that mentioned antimicrobial stewardship.
We describe the historical background behind how antimicrobial stewardship came into use in clinical settings. We discuss challenges emerging from the varied descriptions of antimicrobial stewardship in the literature, including an over-emphasis on individual prescriptions, an under-emphasis on the societal implications of antimicrobial use, and language translation problems.
To help address these challenges, we suggest viewing antimicrobial stewardship as a strategy, a coherent set of actions which promote using antimicrobials responsibly. We stress the continuous need for ‘responsible use’ to be defined and translated into context-specific and time-specific actions. Furthermore, we present examples of actions that can be undertaken within antimicrobial stewardship across human and animal health.
Healthcare systems consist of building blocks. Shaping how these building blocks function and interact can promote responsible antimicrobial use, and this represents an important opportunity for ...managers at different points within healthcare systems to act upon.
To review real-world examples of how healthcare systems can promote responsible antimicrobial use, focusing on the role of governance and managers.
We searched and reviewed existing literature and official documents, which mostly focused on antibiotics. We also drew on the diverse experiences of the ESGAP (the ESCMID (European Society of Clinical Microbiology and Infectious Diseases) Study Group for Antimicrobial stewardshiP) network.
First, we explored at the institution level the implementation of antimicrobial stewardship programmes, the need to embrace multidisciplinary approaches, the benefits of engaging with social sciences experts, and the role of governance and leadership. We look beyond individual institutions and highlight the urgent need for workforce capacity estimates for antimicrobial stewardship activities, how antimicrobial stewardship efforts can connect to form networks, and the importance of governance and regulation at national and international levels.
Managers in the healthcare system are in a strong position to look beyond individual prescriptions and to recognize the many ways in which different healthcare system building blocks can contribute to responsible use of antimicrobials. At the institution level this can be achieved by implementing antimicrobial stewardship programmes, ensuring they are adequately resourced, and driving buy-in across clinical leadership. At regional and national levels this includes facilitating the sharing of experiences and resources between institutions, and developing the standards and regulations needed to support responsible antimicrobial use.
As people are living longer the demand for long-term care facilities (LTCFs) continues to rise. For many reasons, antimicrobials are used intensively in LTCFs, with up to a half of this use ...considered inappropriate or unnecessary. Over-use of antimicrobials can have direct adverse consequences for LTCF residents and promotes the development and spread of resistant bacteria. It is therefore critical that LTCFs are able to engage in antimicrobial stewardship programmes, which have the potential to minimize the antibiotic selective pressure, while improving the quality of care received by LTCF residents. To date, no antimicrobial stewardship guidelines specific to LTCF settings have been published. Here we outline the scale of antimicrobial use in LTCFs and the underlying drivers for antibiotic over-use. We further describe the particular challenges of antimicrobial stewardship in LTCFs, and review the interventional studies that have aimed to improve antibiotic use in these settings. Practical recommendations are then drawn from this research to help guide the development and implementation of antimicrobial stewardship programmes.
The term 'Diagnostic stewardship' is increasingly being used in the literature. This term appears to have emerged in order to address two related and topical aspects of the role of the microbiology ...laboratory in clinical practice today: i) using microbiology diagnostic tests to improve the use of antibiotics, and ii) promoting the appropriate use of microbiology diagnostic methods. While 'Diagnostic stewardship' is catchy, we worry that it may ultimately be a misleading term with the potential to impede communication with non-infection specialists. We present here the views of two ESCMID study group executive committees (ESGMD and ESGAP) with the hope of stimulating further discussion.
Given the current bacterial resistance crisis, antimicrobial stewardship programmes are of the utmost importance. We present a narrative review of the impact of infectious disease specialists (IDSs) ...on the quality and quantity of antibiotic use in acute-care hospitals, and discuss the main factors that could limit the efficacy of IDS recommendations. A total of 31 studies were included in this review, with a wide range of infections, hospital settings, and types of antibiotic prescription. Seven of 31 studies were randomized controlled trials, before/after controlled studies, or before/after uncontrolled studies with interrupted time-series analysis. In almost all studies, IDS intervention was associated with a significant improvement in the appropriateness of antibiotic prescribing as compared with prescriptions without any IDS input, and with decreased antibiotic consumption. Variability in the antibiotic prescribing practices of IDSs, informal (curbside) consultations and the involvement of junior IDSs are among the factors that could have an impact on the efficacy of IDS recommendations and on compliance rates, and deserve further investigation. We also discuss possible drawbacks of IDSs in acute-care hospitals that are rarely reported in the published literature. Overall, IDSs are valuable to antimicrobial stewardship programmes in hospitals, but their impact depends on many human and organizational factors.
To develop a consensus-based set of generic competencies in antimicrobial prescribing and stewardship for European prescribers through a structured consensus procedure.
The RAND-modified Delphi ...procedure comprised two online questionnaire rounds, a face-to-face meeting between rounds, and a final review. Our departure point was a set of competencies agreed previously by consensus among a UK multi-disciplinary panel, and which had been subsequently revised through consultation with ESCMID Study Group representatives. The 46 draft competency points were reviewed by an expert panel consisting of specialists in infectious diseases and clinical microbiology, and pharmacists. Each proposed competency was assessed using a nine-point Likert scale, for relevance as a minimum standard for all independent prescribers in all European countries.
A total of 65 expert panel members participated, from 24 European countries (one to six experts per country). There was very high satisfaction (98%) with the final competencies set, which included 35 competency points, in three sections: core concepts in microbiology, pathogenesis and diagnosing infections (11 points); antimicrobial prescribing (20 points); and antimicrobial stewardship (4 points).
The consensus achieved enabled the production of generic antimicrobial prescribing and stewardship competencies for all European independent prescribers, and of possible global utility. These can be used for training and can be further adapted to the needs of specific professional groups.
To investigate the occurrence of antibiotic residues in different types of environmental samples including water samples in rural Shandong province, China. Further, to characterize the potential ...ecological risk for development of antibiotic resistance in the environment, and the potential direct human health risk of exposure to antibiotics via drinking water and vegetables.
Environmental samples (n = 214) (river water, waste water, drinking water, sediments, manure, soil and edible parts of vegetables) were collected in twelve villages in Shandong province in eastern China. High performance liquid chromatography–tandem mass spectrometry (HPLC–MS/MS) was used to determine the concentration of antibiotic residues. The ratio of the measured environmental concentrations (MEC) to the predicted no-effect concentrations (PNEC) was used to evaluate the ecological risk (risk quotient, RQ) for development of antibiotic resistance. The potential risks to human health through exposure to antibiotics in drinking water were assessed by comparing measured environmental concentrations (MEC) and predicted no-effect concentration in drinking water (PNECDW), and in vegetables by comparing estimated daily intake (EDI) to ADI.
Sulfapyridine, sulfamethoxazole, ciprofloxacin, enrofloxacin, levofloxacin, norfloxacin, chloramphenicol, florfenicol, doxycycline, and metronidazole were detected at concentrations ranging between 0.3 and 3.9 ng/L in river water, 1.3 and 12.5 ng/L in waste water, 0.5 and 21.4 ng/L in drinking water, 0.31 and 1.21 μg/kg in river sediment, 0.82 and 1.91 μg/kg in pig manure, 0.1 and 11.68 μg/kg in outlet sediment, 0.5 and 2.5 μg/kg in soil, and 6.3 and 27.2 μg/kg in vegetables. The RQs for resistance development were >1 for enrofloxacin, levofloxacin, and ranged between 0.1 and 1 for ciprofloxacin. MECs/PNECDW ratios were <1 from exposure to antibiotics through drinking water for both adults and children. EDI/ADI ratios were <0.1 from exposure to antibiotics by vegetable consumption.
Antibiotic pollutants were ubiquitous in various environmental compartments of Shandong province of China. Risk estimates indicated a potential for the measured levels of enrofloxacin, levofloxacin and ciprofloxacin in waste water to pose an ecological risk for resistance selection, and further studies are needed to validate this finding. The investigated antibiotics did not appear to pose an appreciable direct human health risk from environmental exposure through drinking water or vegetables consumption. However, they might still pose a risk for resistance development.
•In Shandong province of China, antibiotic residues were present in various compartments.•Fluoroquinolone in waste water posed potentially moderate and high ecological risk for development of resistance.•The antibiotic did not pose a direct risk to human health, but might cause an important risk of resistance development.
Antibiotic stewardship is a necessity given the worldwide antimicrobial resistance crisis. Outpatient antibiotic use represents around 90% of total antibiotic use, with more than half of these ...prescriptions being either unnecessary or inappropriate. Efforts to improve antibiotic prescribing need to incorporate two complementary strategies: changing healthcare professionals' behaviour, and modifying the healthcare system. In this review, we present a broad perspective on antibiotic stewardship in primary care in high and high-middle income country settings, focussing on studies published in the last five years. We present the limitations of available literature, discuss perspectives, and provide suggestions for where future work should be concentrated.
Abstract
Objectives
To investigate fear of legal claims and defensive behaviours among specialists in infectious diseases (ID) and clinical microbiology (CM) and to identify associated demographic ...and professional characteristics.
Methods
AntibioLegalMap was an international cross-sectional internet-based survey targeting specialists in ID and CM. Three variables were explored: fear of legal liability in antibiotic prescribing/advising on antibiotic prescription; defensive behaviours in antibiotic prescribing; and defensive behaviours in advising. A multivariable logistic regression analysis was performed to identify factors significantly associated with each of the three variables.
Results
Eight hundred and thirty individuals from 74 countries participated. Only 0.4% (3/779) had any kind of condemnation for malpractice related to antibiotic prescription. Concerning the fear of liability, 21.2% (164/774) of respondents said they never worried, 45.1% (349/774) sometimes worried and 28.6% (221/774) frequently worried when prescribing/advising on antibiotic prescription. Being female, younger than or equal to 35 years and aware of previous cases of litigation were independently associated with fear. Most respondents (85.0%, 525/618) reported some defensive behaviour in antibiotic prescribing. These behaviours were independently associated with being younger than or equal to 35 years and sometimes or often worried about liability. Similarly, 76.4% (505/661) reported defensive behaviours in advising. These behaviours were associated with being sometimes or often worried about liability. The preferred measures to reduce fear and defensive behaviours were having local guidelines and sharing decisions through teamwork.
Conclusions
A significant proportion of specialists in ID and CM reported some form of defensive behaviour in prescribing or advising to prescribe antibiotics. Defensive medicine should be considered when implementing antibiotic stewardship programmes.
To learn about medical students' knowledge of and perspectives on antibiotic prescribing and resistance, with the aim of helping to develop educational programmes.
Final-year students at seven ...European medical schools were invited to participate in an online survey in 2012.
The response rate was 35% (338/961). Most students (74%) wanted more education on choosing antibiotic treatments. Students at all schools felt most confident in diagnosing an infection and least confident in choosing combination therapies, choosing the correct dose and interval of administration and not prescribing in cases of diagnostic uncertainty. Students felt that too many prescriptions and too much broad-spectrum antibiotic use were the most important contributors to resistance; some (24%) believed poor hand hygiene was not at all important. Most students (92%) believed that resistance is a national problem. Most (66%) felt that the antibiotics they would prescribe would contribute to resistance, and almost all (98%) felt that resistance would be a greater problem in the future. Most students (83%) incorrectly thought that rates of methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia had significantly increased over the past decade in their countries. There was little appreciation of the relative burden of resistance in Europe compared with road traffic accidents (around two to three times greater mortality) and lung cancer (around 10 times greater mortality).
Students wanted further education on antibiotic prescribing, and areas of lack of confidence were found. Students overestimated the current burden of resistant bacteria and were unaware of successes in reducing MRSA infections. Educational and stewardship programmes may benefit from including more cases of diagnostic uncertainty, and highlighting successes such as MRSA prevention, as evidence for the importance of current interventions.
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