July 2015
clinical initiatives, research and current updates in treatment
The need for an Antimicrobial Stewardship Program Anthony Fico, Epic Pharmacy Murdoch
The risk of a return to the ‘pre-antibiotic’ era Up to 50% of antimicrobial regimens prescribed in Australian hospitals are considered inappropriate.1 Inappropriate use of antimicrobials contributes to the emergence of resistant bacteria and infections with multi-resistant bacteria, a risk of patient harm from avoidable adverse reactions and interactions with other drugs and unnecessary costs. Of greatest concern is the increasing emergence of antimicrobial resistance (AMR) which the World Health Organisation rates as a global health security threat requiring a concerted cross-sectional action by governments and society as a whole.1 No major new types of antibiotics have been developed in the last thirty years and the lack of new agents along with increasing AMR could return society to the ‘pre-antibiotic’ era where we are unable to treat certain infections.
Antimicrobial Stewardship An Antimicrobial Stewardship (AMS) program is the combination of a range of strategies and interventions designed to improve and measure the appropriate use of antimicrobials by promoting the selection of the optimal antimicrobial drug, dose, duration of therapy and route of administration, with the aim of improving patient safety and quality
of care. Comprehensive and successful AMS programs have been shown to:2 ¬ ¬ Reduce inappropriate antimicrobial use (by 22% to 36%) ¬ ¬ Improve patient outcomes ¬ ¬ Reduce antimicrobial resistance ¬ ¬ Reduce healthcare costs National Safety and Quality Health Service (NSQHS) Standard 3: Preventing and Controlling Healthcare Associated Infections, includes the requirement that an AMS program is in place as a core criterion (3.14) for hospital accreditation. Other specific actions required to achieve criterion 3.14 are: ¬ ¬ The clinical workforce prescribing antimicrobials have access to current endorsed therapeutic guidelines on antibiotic usage ¬ ¬ Monitoring antimicrobial usage and resistance is undertaken ¬ ¬ Action is taken to improve the effectiveness of AMS The success of AMS depends on the explicit support of the hospital administration, the allocation of adequate resources and the cooperation and engagement of prescribers.2 Multidisciplinary teams help implement the kind of improvements and changes required for effective AMS. The involvement of both an Infectious Disease (ID) physician (and/or microbiologist)
and a pharmacist (with ID training, if possible) as core team members is considered essential to effective programs. Where an onsite ID physician or a clinical microbiologist is not available, the AMS team should be led by an interested clinician with a clinical pharmacist and they should seek external support for AMS activities.2,4
Strategies for implementing AMS Five strategies are considered essential for effective AMS in Australia. They are:2 ¬¬ Implementing clinical guidelines that are consistent with the latest version of Therapeutic Guidelines: Antibiotic (current version 15 – released November 2014), and which take into account local microbiology and antimicrobial susceptibility patterns. ¬¬ Establishing formulary restrictions and approval systems that include restricting broad-spectrum and later generation antimicrobials to patients in whom their use is clinically justified. Types of restriction mechanisms recommended include:5 –– Expert approval: require a nominated expert (e.g. ID physician) to have input or involvement in the prescribing of the antimicrobial agent –– Criteria-based: outline specific conditions that must be met for an antimicrobial prescription to be automatically approved