Antimicrobial stewardship (AMS) describes a coherent set of actions that ensure optimal use of antimicrobials to improve patient outcomes, while limiting risk of adverse events (including antimicrobial resistance [AMR]). Introduction of AMS programs in hospitals is part of most national action plans to mitigate AMR, yet the optimal components and actions of such a program remain undetermined.
Mendelson, et al. (2019) describe how healthcare professionals can start an antimicrobial stewardship programme in their hospital, the components of such a program, and the evidence base for its implementation.
As the researchers observe, "Antimicrobial stewardship programs in hospitals are a vital component of national action plans for antimicrobial resistance, and have been shown to significantly reduce AMR, particularly when coupled with infection prevention and control interventions."
They add further, "National action plans to tackle antimicrobial resistance (AMR) exist in an increasing number of countries. AMS, a coherent set of actions, which promote the optimal use of antimicrobials in ways that ensure sustainable access to effective therapy for all in need, is one cornerstone of any national policy, and the foundation of a hospital’s antimicrobial stewardship program (ASP) to optimize antimicrobial use and patient outcomes."
Briefly, the general framework of an ASP has ideally three components, the researchers say: 1) There are system prerequisites (=structures) that must be met before implementation (e.g. presence of guidelines, AMS team, adequate diagnostic, human and IT resources); 2) WHAT the AMS team wants to improve (=processes that need to be addressed) must be clearly defined (recommendations on appropriate use at the patient level, e.g. duration of treatment compliant with guidelines); and finally 3) HOW the AMS team will achieve these goals must be planned, i.e. the improvement strategies that will be chosen and tailored based on the identified determinants and problems and performed by the team at the professional or institutional level (e.g. audit and feedback, education).
National action plans to tackle antimicrobial resistance (AMR) exist in an increasing number of countries. AMS, a coherent set of actions, which promote the optimal use of antimicrobials in ways that ensure sustainable access to effective therapy for all in need, is one cornerstone of any national policy, and the foundation of a hospital’s ASP to optimize antimicrobial use and patient outcomes.
The researchers say the following core elements are necessary:
1. Senior hospital management leadership toward antimicrobial stewardship
- Has your hospital management formally identified AMS as a priority objective for the institution and included it in its key performance indicators?
- Is there dedicated, sustainable and sufficient budgeted financial support for AMS activities (e.g., support for salary, training, or information technology support)?
- Does your hospital follow any (national or international) staffing standards for AMS activities (e.g. number of full-time equivalent per 100 beds for the different members of the AMS team)?
2. Accountability and responsibilities
- Does your hospital have a formal/written AMS programme/strategy accountable for ensuring appropriate antimicrobial use?
- Does your hospital have a formal organizational multidisciplinary structure responsible for AMS (e.g., a committee focused on appropriate antimicrobial use, pharmacy committee, patient safety committee or other relevant structure)?
- Is there a healthcare professional identified as a leader for AMS activities at your hospital and responsible for implementing the program?
- Is there a document clearly defining roles, procedures of collaboration and responsibilities of the AMS team members?
- Are clinicians, other than those part of the AMS team (e.g. from the ICU, Internal Medicine and Surgery) involved in the AMS committee?
- Does the AMS committee produce regularly a dedicated report which includes e.g. antimicrobial use data and/or prescription improvement initiatives, with time-committed short term and long-term measurable goals/targets for optimising antimicrobial use?
- Is there a document clearly defining the procedures of collaboration of the AMS team/committee with the infection prevention and control team/committee?
3. Available expertise on infection management
- Do you have access to laboratory/imaging services and to timely results to be able to support the diagnosis of the most common infections at your hospital?
- In your hospital are there, or do you have access to, trained and experienced healthcare professionals (medical doctor, pharmacist, nurse …) in infection management (diagnosis, prevention and treatment) and AMS willing to constitute an AMS team?
4. Education and practical training
- Does your hospital offer a range of educational resources to support staff training on how to optimize antimicrobial prescribing?
- Do the AMS team members receive regular training in antimicrobial prescribing and AMS?
5. Other actions aiming at responsible antimicrobial use
- Is a multidisciplinary AMS team available at your hospital (e.g., greater than one trained staff member supporting clinical decisions to ensure appropriate antimicrobial use)?
- Does your hospital support the AMS activities/strategy with adequate information technology services?
- Does your hospital have an antimicrobial formulary (i.e. a list of antimicrobials that have been approved for use in a hospital, specifying whether the drugs are unrestricted, restricted (approval of an AMS team member is required) or permitted for specific conditions)?
- Does your hospital have available and up-to-date recommendations for infection management (diagnosis, prevention and treatment), based on international/national evidence-based guidelines and local susceptibility (when possible), to assist with antimicrobial selection (indication, agent, dose, route, duration) for common clinical conditions?
- Does your hospital have a written policy that requires prescribers to document an antimicrobial plan (includes indication, name, dosage, duration, route and interval of administration) in the medical record or during order entry for all antimicrobial prescriptions?
- Does the AMS team review/audit courses of therapy for specified antimicrobial agents or clinical conditions at your hospital?
- Is advice from AMS team members easily available to prescribers?
- Are there regular infection and antimicrobial prescribing focused ward rounds in specific departments in your hospital?
6. Monitoring and surveillance (on a continuous basis)
- Does your hospital monitor the quality/appropriateness of antimicrobial use at the unit and/or hospital wide level?
- Does your AMS program monitor compliance with one or more of the specific interventions put in place by the AMS team (e.g. indication captured in the medical record for all antimicrobial prescriptions)?
- Does your hospital monitor antibiotic susceptibility rates for a range of key bacteria?
- Does your hospital monitor the quantity of antimicrobials prescribed/dispensed/purchased at the unit and/or hospital wide level?
7. Reporting and feedback (on a continuous basis)
- Does your AMS program share hospital-specific reports on the quantity of antimicrobials prescribed/dispensed/purchased with prescribers?
- Does your AMS program share facility-specific reports on antibiotic susceptibility rates with prescribers?
- Are results of audits/reviews of the quality/appropriateness of antimicrobial use communicated directly with prescribers?
Reference: Mendelson M, et al. How to start an antimicrobial stewardship program in a hospital. Clinical Microbiology and Infection. Clinical Microbiology and Infection. Aug. 22, 2019.