"No Action Today, No Cure Tomorrow": IDSA Stewardship
Thomas M. Hooton, M.D.
Professor of Clinical Medicine
Lillian Abbo, M.D.
Assistant Professor of Clinical Medicine
University of Miami, Miller School of Medicine
Mrs. B was a pleasant 56-year old female with a long history of primary biliary cirrhosis who underwent a liver transplantation. Her post-operative course was complicated by recurrent hospitalizations with abdominal wound dehiscence (splitting open) and failure to heal. She was diagnosed with a postoperative wound infection and was treated with appropriate antibiotics. Her abdominal wound improved, but she was hospitalized three months later with shortness of breath and failure to thrive. She developed septic shock and required intubation with mechanical ventilation. Blood and respiratory cultures revealed a multidrug resistant Acinetobacter baumanii, susceptible only to meropenem and colistin. Despite two weeks of appropriate antimicrobial therapy, she remained bacteremic and no clear focus of infection could be identified. After three weeks with persistent bacteremia, the organism became resistant to all drugs including colistin. The patient never cleared the bacteremia and ultimately died.
If you have any doubt that we are getting closer to the pre-antibiotic area, you are probably wrong. Perhaps you will be the next physician taking care of a patient with a multidrug resistant infection or, worse (depending on one’s perspective), you yourself could contract a multidrug resistant organism for which there is no effective antimicrobial therapy available. Unfortunately this is not science fiction, or a new unknown infection from an exotic land. Antimicrobial resistance is a serious problem worldwide - there are no new options to treat multidrug resistant gram-negative organisms, with very few drugs in the development pipeline.
This year, The World Health Organization (WHO) selected “combat antimicrobial resistance” as the theme for World Health Day. On April 7, 2011, WHO issued an international call for concerted action to halt the spread of antimicrobial resistance and recommends a 6-point package of policies for governments and stakeholders to prevent and counter the emergence of highly resistant microorganisms. Development of new antimicrobials is one of the issues. We agree that the development of new drugs for multidrug resistant organisms should be a public health priority; nonetheless, "The development of new antibiotics without having mechanisms to insure their appropriate use is much like supplying your alcoholic patients with a finer brandy." (Dennis Maki, IDSA meeting, 1998).
In an effort to improve the appropriate use of antibiotics and prevent the development of further antimicrobial resistance, the Infectious Diseases Society of America published in 2007 the “Guidelines for Developing an Institutional Program to Enhance Antimicrobial Stewardship”. The purpose of an Antimicrobial Stewardship Program (ASP) is to improve patient care by optimizing selection, dosing, route, and duration of antimicrobial therapy to maximize clinical cure or prevention of infection while limiting the unintended consequences, such as the development of resistance, adverse drug events, and costs. Successful programs have been shown to improve patient care while being financially self-supporting.
As discussed in the IDSA ASP guidelines3, there are two core strategies recommended for use by ASPs:
Prospective audit and feedback
Formulary restriction and preauthorization
Other important components to effectively impact the appropriate use of antibiotics are:
Guidelines and clinical pathways
Antimicrobial order forms or electronic order sets
Streamlining or de-escalation of empirical antimicrobial therapy
Optimization of antimicrobial dosing
Parenteral to oral conversion
Health care information technology
The clinical microbiology laboratory plays a critical role in antimicrobial stewardship by providing patient-specific culture and susceptibility data to optimize individual antimicrobial management and by assisting infection control efforts in the surveillance of resistant organisms. Rapid molecular diagnostics are urgently needed to assist in the selection of appropriate empiric antimicrobial therapy, and to avoid the prolonged unnecessary use of antimicrobial agents while awaiting culture results.
It is extremely important that physicians recognize the need for, and the value of, ASPs and support their existence in hospitals. The optimal structure and components of ASPs will vary according to local circumstances. However, a successful program requires the involvement of well trained and enthusiastic physicians and pharmacists and the strong support of the hospital administration and medical staff. Interested physicians and pharmacists can usually demonstrate to institutions that an ASP can pay for itself in short order by reducing pharmacy costs and reducing length of stays.
In summary, we need to use our resources wisely; “to widen access to appropriate medications to encompass all people – regardless of race, gender, or socio-economic status – while at the same time reserving these precious compounds to treat only those diseases for which they are specifically required”. Our grandparents lived during an age without antimicrobials. The potential of drug resistance to catapult us all back into a world of premature death and chronic illness is all too real. As we age and ponder our inevitable entry into the age demographic in which our risk of hospitalization is not negligible, such as for joint replacement or other such procedure, it is worth thinking about how we might react to acquiring a prosthetic device MRSA infection or a multidrug-resistant Pseudomonas or Acinetobacter pneumonia. We must all recognize the seriousness of this problem and commit ourselves to using these precious resources wisely. Many of us believe that knowingly using antimicrobials in situations where they are not indicated is unethical. ASPs can help us identify such situations and avoid inappropriate antimicrobial use. We have the means to ensure that our antimicrobial armamentarium remains effective, but we are running out of time. Please support (or initiate) your local antimicrobial stewardship program. The time to act is today.
For additional information:
STAAR Act Rationale for AR Surveillance and Research
STAAR Act Highlights
STAAR Act Brief Summary
For guidelines: http://cid.oxfordjournals.org/content/44/2/159.full.pdf
For more information on Diagnostics see APUA Newsletter Vol. 25 No. 1