By the end of this article, readers should be able to: (1) describe the objectives of antimicrobial accountability and discuss why there is a growing need for antimicrobial stewardship programs; (2) identification of stewardship techniques that can be used in various hospital settings by different health care professionals; and (3) list the steps to be taken to initiate a stewardship program and identify potential barriers to implementation. A: The more antibiotics are used, the less effective they become. When bacteria are exposed to antibiotics, bacteria adapt and become increasingly able to defeat drugs. This development can be gradual or rapid, but any use of antibiotics accelerates the process. Unfortunately, the data shows a high level of unnecessary antibiotic prescribing in healthcare facilities in the United States. For example, 1 in 3 antibiotic prescriptions written in doctors` offices, emergency rooms and hospital clinics – about 47 million prescriptions per year – is completely useless. Effective antibiotic management can reduce this type of abuse and help slow the development of resistance. Perhaps the biggest barrier to developing a stewardship program is personnel costs. Many administrators view stewardship as part of the infectious disease consultant`s job, yet consultants are not able to charge for liability. Currently, there is no mechanism for direct reimbursement of stewardship programs and, therefore, costs must be justified by demonstrating the savings achieved by the institution. A common perception is also that stewardship will lead to a decrease in the number of consultations.
In fact, stewardship programs should aim to complement and support the advisory service, and may even lead to an increase in the number of referrals. On September 18, 2014, President Barack Obama issued Executive Order 13676, “Combating Antibiotic-Resistant Bacteria.” This decree mandated a working group to develop a 5-year action plan that included measures to reduce the emergence and spread of antibiotic-resistant bacteria and ensure the continued availability of effective therapies against infections. The improvement of the AMS is one of the burdens of this decree. The Presidential Advisory Council on the Control of Antibiotic-Resistant Bacteria (PACCARB) was created in response to this decree. [16] [17] The second objective is to prevent the overuse, abuse and abuse of antimicrobials. Both in the hospital and in the outpatient area, doctors use antibiotics when they are not needed. Antibiotics are given to patients with viral infections, non-infectious processes (a classic example is the febrile patient with pancreatitis), bacterial infections that do not require antibiotics (such as small skin abscesses that dissolve with incision and drainage) and bacterial colonization (as in the case of a positive urine culture leading to a patient with a bladder catheter). Antibiotics are also frequently used, as in the very common scenario of the use of broad-spectrum antibiotics that cover multidrug-resistant organisms in a patient whose infection has been contracted in the community, or the inability to adjust antibiotics based on culture data, thus keeping the patient on a diet to which the body is not sensitive. The misuse of antibiotics is more difficult to define, but the term could be used to describe the use of a particular antibiotic preferred over others by a doctor as a result of aggressive details by the pharmaceutical representative or worse for financial reasons. Tens of thousands of Americans die each year from infections caused by antibiotic-resistant pathogens. Every day, patients die from bacterial infections for which no active ingredients are available. However, since 1998, only 10 new antibiotics have been approved, of which only 2 (linezolid and daptomycin) actually have new efficacy targets.
The reasons for this are simple: drug development is risky and expensive, and drugs used to treat infections are not as cost-effective as those that treat chronic diseases. Antibiotics currently in development are part of the existing classes and are very varied, which means that they are likely to further promote the development of resistance if approved and used. In hospitals, it is estimated that 50% of antibiotic orders are useless.8 In this environment, broad-spectrum antibiotics are used unbridled. It is also in this environment that the most dangerous and extreme drug resistance has been observed. All of this has led the Infectious Diseases Society of America`s Bad Bugs, No Drugs task force to call for global stakeholder engagement to support the development of 10 new drugs in new classes by 2020. This initiative known as 10 × 20 has been compared to John F. Kennedy`s dream of running on the moon. Pew`s ongoing collaboration with the CDC has produced national-level data on antibiotic use that serves as the basis for national goals to reduce inappropriate antibiotic use by 2020. Pew is also advocating for mandatory reporting of antibiotic resistance, using data from the center`s National Healthcare Safety Network to track resistance trends and improve antibiotic prescribing. APIC – Society for Healthcare Epidemiology of America Position Paper in antimicrobial stewardship In 2014, the CDC recommended that all U.S.
hospitals have an antibiotic management program (ASP). [18] Stewardship programs also help ensure that antibiotics are used appropriately when needed. Proper application helps slow down the development of resistance by optimizing a patient`s treatment. For example, an analysis of antibiotic selection in the United States conducted by the Centers for Disease Control and Protection and The Pew Charitable Trusts showed that for some common conditions, only half of patients receive the recommended first-line antibiotic according to medical guidelines. This research also found that when patients are given an inappropriate antibiotic, it is most often a broad-spectrum drug such as azithromycin. A broad spectrum means that the drug acts against a wide range of bacteria, but studies show that people who receive these drugs are more likely to develop resistant infections than those treated with more targeted antibiotics. As the treatment of hospitalized patients becomes increasingly complex, the increasing prevalence of antimicrobial resistance poses a formidable challenge both in health care and in the community. With the increasing complexity of infections and the lack of new antimicrobials in development, the future of successful antimicrobial therapy looks bleak.
Antimicrobial stewardship can provide tools for all practitioners to prevent overuse of valuable resources and control the rise of antimicrobial resistance. Although often underestimated, the increase in antimicrobial resistance has finally attracted the attention of influential international health organizations. The Institute of Medicine has identified antibiotic resistance79 as one of the most significant microbial threats to health in the United States and has listed reducing inappropriate antimicrobial use as the primary solution to address this threat. The Get Smart campaign, launched in 1995 by the Centers for Disease Control and Prevention, focused on reducing the use of inappropriate antimicrobials on an outpatient basis. In 2010, the Centers for Disease Control and Prevention launched Get Smart for Healthcare, a campaign focused on improving the use of antibiotics in inpatient healthcare facilities to prevent antimicrobial overuse and promote the use of antimicrobial liability. The World Health Organization`s World Health Day 2011 focused on international antimicrobial resistance.