Antimicrobial stewardship

Email: p.lebrun@

Worldwide resistance to antibiotics is on the increase and becoming more and more of a problem in the treatment of infectious diseases. In The Netherlands, the realisation has sunk in that increasing resistance to antibiotics is becoming a real threat, while at the same time not enough new antibiotics are being developed. For example, the increase of extended-spectrum b-lactomase-producing Gram-negative microorganisms is of great concern. Since 1996, a national working group (the so-called SWAB, in which microbiologists, doctors of infectious diseases and hospital pharmacists participate) co-ordinates the antibiotic policy in The Netherlands. This working group was recently asked by the Inspectorate to define which measures are necessary to guarantee the successful treatment of infectious diseases in the future. This resulted in a policy based on:

The latter is considered to be a condition for a coherent antibiotic policy. The core action is to form an Antibiotic team (A-team) in every hospital. These teams are comprised of microbiologists, doctors of infectious diseases, hospital pharmacists and quality assurance personnel. The A-team focuses on authorisation of antibiotics for special indications, supervises antibiotic guidelines, organises special projects, education and training and has a consultative function in case of treatment of a patient at risk.

The installation of A-teams in all hospitals will be mandatory by 2014, which is why most hospitals are starting up already. To date, successful special projects have included Switch projects (a policy to encourage the switch from IV to oral administration as soon as possible), a start – stop policy for (antibiotics) and the collection of antibiotic data (defined daily dose, resistance patterns) in order to benchmark antibiotic use in The Netherlands.

Antimicrobial stewardship refers to coordinated interventions designed to improve and measure the appropriate use of antimicrobials by promoting the selection of the optimal antimicrobial drug regimen, dose, duration of therapy, and route of administration. Antimicrobial stewards seek to achieve optimal clinical outcomes related to antimicrobial use, minimise toxicity and other adverse events, reduce the costs of healthcare for infections, and limit the selection for antimicrobial-resistant strains. Currently, in Italy there are no national or coordinated legislative or regulatory mandates designed to optimise use of antimicrobial therapy through antimicrobial stewardship.

Given the societal value of antimicrobials and their diminishing effectiveness due to antimicrobial resistance, the Health Ministry supports a broad implementation of antimicrobial stewardship programs across all healthcare settings (for example, hospitals, long-term care facilities, long-term acute care facilities, ambulatory surgical centres, dialysis centres and private practices). Many Italian hospitals follow national guidelines on surgical antibiotic prophylaxis and on antibiotic therapy to control infections, while some others have implemented their own antimicrobial control strategies. Despite the fact that all hospital centres have implemented an antimicrobial stewardship program, significant differences exist between them. To face these differences, projects must be implemented at local level.

There is overwhelming evidence of a causal relationship between antimicrobial use and the development of healthcare-acquired infections (HCAI) both at the individual and population level. The incurred health burden caused by HCAIs such as meticillin–resistant Staphylococcus aureus (MRSA) and Clostridium difficile infection is significant in terms of increased morbidity, mortality and costs. Further, there has been less emphasis on the development of new antimicrobials by the pharmaceutical industry.

Whilst antimicrobial resistance is a multi-factorial problem, one of the key components is the optimisation of antimicrobial use via stewardship which aims to ensure clinical cure whilst limiting the unintended consequences of antimicrobial use.

The Chief Medical Officer for England’s Report in 2011 focussed in an in-depth manner on infectious diseases and the rise of antimicrobial resistance including the importance of stewardship. Guidance was also introduced in 2011 entitled Start Smart and then Focus. The key elements of an antimicrobial stewardship programme were highlighted, namely:

There have been similar reports and work in Scotland by the Scottish Antimicrobial Prescribing Group and likewise in Wales, with a framework document for eliminating preventable HCAIs being published in 2011. In Northern Ireland, the Strategy for Tackling Antimicrobial Resistance (STAR) will shortly be published.

However, in order to ensure high-quality stewardship, there must be timely feedback to clinicians to inform their practice and also the ability to identify as early as possible potential problems with emerging organism resistance. The use of technology via software packages for the  ongoing monitoring of antimicrobial use with linkage to resistance data from laboratories is therefore a key enabler in this regard.

A national antibiotic stewardship program is essential for long-lasting antibiotic usage and for the control of antimicrobial resistance in the hospital setting.

Development of antibiotic resistance is not as fast in the Czech Republic compared with other European countries, but it is on the increase nevertheless. The main reason for is that antibiotics are available only through prescription, and therefore antibiotic resistance rates are relatively low for pathogens in the community.

There is a defined structure for the antibiotic centres in Czech hospitals. The majority of the centres are integrated in clinical microbiology departments.

Only a few are managed by infectious diseases specialists. Specialists from the antibiotic centres provide daily consultations and supervise antibiotic use. In some of our hospitals, antibiotics are only administered following recommendations from the antibiotic centre. Microbiologists sometimes attend clinical rounds in intensive care units and provide bedside or on-call consultations. However, sufficient control of antibiotic consumption is not implemented in all Czech hospitals.

Hospital pharmacists have very precise data about antibiotic consumption. They can interact with microbiologists and sit on hospital drug committees, and participate in the development of antibiotic and antimicrobial policies. These data are important sources for antibiotic pharmacoepidemiology. Clinical pharmacists usually answer pharmacological queries regarding antibiotic pharmakokinetics, interactions etc.

The implementation of multidisciplinary antibiotic teams, including microbiologists, infectious disease specialists, intensivists, other clinicians and pharmacists, could result in better progress in antibiotic stewardship.

The surveillance report of the European Centre for Disease Prevention and Control (ECDC) on antimicrobial consumption in Europe ranks Germany in the quartile with the lowest use density of systemic antibacterials. Striking however is, that Germans are much more likely to use cephalosporins, macrolides and quinolones instead of penicillins when it comes to treat bacterial infections. On the background of an ongoing battle against multiresistant bacteria, the appropriate selection of antimicrobials is mandatory.

In order to reach this goal, many countries have implemented ‘Antimicrobial Stewardship’ programs that are not restricted to specialists on infectious diseases but rather include other health care professionals as well. Under the auspieces of the German Ministry of Health and in collaboration with a number of other Societies, the German Society for Infectiology (DGI) has developed an educational program named ‘Antibiotic Stewardship’ (ABS) which is offered to physicians and pharmacists.

The ABS program has four different levels ranging from ‘basic’ to ‘expert’ each of which leaves the participants with a substantial amount of knowledge on the proper use of antimicrobial agents. The courses have become an unprecedented success and due to a long waiting list are only open on a ‘first come first serve’ base. Part of the success might be that not only the audience but also the teaching staff is interdisciplinary. A number of hospital pharmacists, most of which are members of the working party on anti-infective therapy of the German Society of Hospital Pharmacists (ADKA), give lectures on all kinds of subjects ranging from basic microbiology to pharmacoeconomics of antibacterial agents. The ABS program however is not the only project where hospital pharmacists and infectiologists work together. For several years both societies have conducted their very own surveillance project studying the consumption of antiinfectives in German hospitals. Future will tell whether programs such as Antibiotic Stewardship are successful in keeping microbes at bay.