Over the past 30 years, many multidrug-resistant organisms have emerged across healthcare settings in the United States. At the same time, there has been a dramatic drop in the development and approval of new antibiotics. “The antimicrobial armamentarium has been depleted,” explains Neil Fishman, MD. “As a result, our ability to treat infectious diseases has been severely compromised. Resistant infections are increasing morbidity and mortality while simultaneously increasing healthcare costs.”
Research has shown that a multifaceted approach is required to prevent, detect, and control the emergence of antimicrobial-resistant organisms. This includes ensuring that effective and appropriate therapeutic agents are available and that healthcare settings have the diagnostic capacity to rapidly and reliably detect specific pathogens and their antimicrobial susceptibilities.
Promoting better infection prevention and control practices and antimicrobial stewardship programs is important in reducing the burden of infectious diseases, Dr. Fishman says. More healthcare facilities nationwide are launching antimicrobial stewardships because they have the potential to reduce the emergence and transmission of resistant pathogens and decrease antimicrobial resistance.
A Joint Position Statement on Antimicrobial Stewardship
In the April 2012 issue of Infection Control and Hospital Epidemiology, the Society for Healthcare Epidemiology of America (SHEA), the Infectious Diseases Society of America (IDSA), and the Pediatric Infectious Diseases Society (PIDS) published a joint position paper focusing on the need for public policy around the issue of antimicrobial stewardship. SHEA, IDSA, and PIDS have been at the forefront of addressing the need for antimicrobial resistance programs for many years, says Dr. Fishman, co-author of the position paper. “Great efforts are needed to improve prevention and control practices throughout the country.”
Key Recommendations for Antimicrobial Programs
In the position paper, the societies offer key recommendations on antimicrobial stewardships, starting with requiring that all healthcare institutions have established regulatory mechanisms for planning of these programs (Table 1). SHEA, IDSA, and PIDS recommend that CMS require participating healthcare institutions to develop and implement antimicrobial stewardship programs. “This can be achieved by incorporating the requirement into existing regulations,” Dr. Fishman says. All healthcare facilities should develop and implement antimicrobial stewardship plans that are modeled after guidelines for developing institutional programs to enhance antimicrobial stewardship.
The position paper adds that it is critical to monitor antimicrobial stewardship in all ambulatory healthcare settings, ranging from outpatient clinical practices to dialysis centers. “Currently, we don’t have effective mechanisms to optimize antimicrobial use in ambulatory healthcare settings,” says Dr. Fishman. “There is plenty of evidence suggesting that antimicrobial resistance is emerging as a problem in the community. Effective and efficient antimicrobial stewardship initiatives must be developed for these settings.”
In addition, the SHEA/IDSA/PIDS position paper recommends increasing education about antimicrobial resistance and stewardship to overcome knowledge deficits among healthcare providers. Educational programs should be developed for those in training as well as for all prescribing clinicians. It should also be incorporated into curriculum requirements for medical students and postgraduate residents and fellows. Practicing clinicians must become proficient in these areas, Dr. Fishman says. “Individual facilities should make every effort to support the education of their staff on antimicrobial stewardship.”
In both inpatient and outpatient settings, it is recommended that data on antimicrobial use be collected and readily available. “Accurate and readily available data to track and benchmark antimicrobial use are lacking in the U.S.,” says Dr. Fishman. “These data are critical to monitoring antimicrobial use and its relationship to resistance.” Establishing reliable and accurate methods for collecting such data is paramount to optimizing the development of antimicrobial stewardship programs. Such plans can help providers know when antibiotics are needed and which ones should be used in particular cases to improve care and prevent future resistance.
More Research Needed on Antimicrobial Resistance
The problem of antimicrobial resistance throughout healthcare has been well documented in the medical literature, but more research is needed on antimicrobial stewardship to increase clinicians’ understanding of resistance (Table 2). “We also need more data on interventions that appear to limit the emergence and transmission of resistance,” Dr. Fishman says. “Finding ways to optimize the measurable impact of antimicrobial stewardship on clinical outcomes is also important.”
Effective antimicrobial stewardship programs will improve outcomes, conserve limited resources, and reduce the emergence of resistance, says Dr. Fishman. “There are few antibiotics in the pharmaceutical pipeline. We must take the necessary measures to preserve our current supply of antibiotics and ensure that our patients have access to these medications. Antimicrobial stewardship can immediately address this issue and protect the effectiveness of the next generation of antibiotics.”
Readings & Resources (click to view)
SHEA, IDSA, PID. Policy statement on antimicrobial stewardship by the Society for Healthcare Epidemiology of America (SHEA), the Infectious Diseases Society of America (IDSA), and the Pediatric Infectious Diseases Society (PIDS). Infect Control Hosp Epidemiol. 2012;33:322-327. Available at: http://www.jstor.org/stable/10.1086/665010.
Fishman N, Srinivasan A. Antimicrobial stewardship 2012: science driving practice. Infect Control Hosp Epidemiol. 2012;33:319-321.
Dellit TH, Owens RC, McGowan JE Jr, et al. Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clin Infect Dis. 2007;44:159-177.
Spellberg B, Blaser M, Guidos RJ, et al for the Infectious Diseases Society of America. Combating antimicrobial resistance: policy recommendations to save lives. Clin Infect Dis. 2011;52(suppl 5):S397-S428.
Gilbert DN, Spellberg B, Bartlett JG for the Infectious Diseases Society of America. Position paper: an unmet medical need: rapid molecular diagnostic tests for respiratory tract infections. Clin Infect Dis. 2011;52(suppl 4):S384-S395.
Moody J, Cosgrove SE, Olmsted R, et al. Antimicrobial stewardship: a collaborative partnership between infection preventionists and health care epidemiologists. Infect Control Hosp Epidemiol. 2012;33:328-330.
Standiford HC, Chan S, Tripoli M, Weekes E, Forrest GN. Antimicrobial stewardship at a large tertiary care academic medical center: cost analysis before, during, and after a 7-year program. Infect Control Hosp Epidemiol. 2012;33:338-345.
Stevenson KB, Balada-Llasat J, Bauer K, et al. The economics of antimicrobial stewardship: the current state of the art and applying the business case model. Infect Control Hosp Epidemiol. 2012;33:389-397.