Antimicrobial stewardship

After first appearing in the medical literature in 1996,32 the term antimicrobial stewardship has become an increasingly popular idea to help contain AMR and sustain antibiotic effectiveness.


Continue Reading

Merriam-Webster defines stewardship as “the conducting, supervising, or managing of something; especially the careful and responsible management of something entrusted to one’s care.” Similar to environmental campaigns, which emphasize the earth’s limited natural resources and challenge us to live in a more environmentally friendly manner, antimicrobial stewardship campaigns challenge clinicians to be better stewards of our antimicrobial resources.

Antimicrobial stewardship encompasses a range of formal and informal approaches designed to conserve antibiotics, including educational programs, clinical guidelines, committees, and surveillance policies.33,34 Inpatient, outpatient and combined inpatient/outpatient antimicrobial stewardship campaigns do exist.

The CDC’s Get Smart campaign is considered one of the best examples of a combined inpatient/outpatient campaign35 and provides a wealth of evidence-based information and resources for patients and clinicians alike. In addition, antimicrobial stewardship campaigns have a small but growing body of research to support their effectiveness.34,36,37 For clinicians who choose not to join or start an antimicrobial stewardship group, committing to the 10 antibiotic prescribing principles is an excellent way to demonstrate antimicrobial stewardship.

Conclusion

Like water, soil and fossil fuels, antibiotics ought to be considered precious resources that require responsible management. If we are not vigilant about appropriate antibiotic prescribing now, a “postantibiotic era” will be inevitable.

NPs and PAs have a long history of providing safe, high-quality care. As experts in health care, NPs and PAs should assume a leading role in the antimicrobial stewardship campaign. At a minimum, NPs and PAs should consider adopting the aforementioned10 appropriate antibiotic prescribing principles.

Ann-Marie Hart, PhD, FNP-BC, is associate professor and coordinator of the Doctor of Nursing Practice program at the Fay W. Whitney School of Nursing, University of Wyoming, in Laramie.

References

  1. World Health Organization. Combat Drug Resistance: No action today, no cure tomorrow.
  2. Fleming A. On the antibacterial action of cultures of penicillium, with special reference to their use in the isolation of B. influenzae. Br J Exp Pathol. 1929;10:226-236.
  3. Fleming A. Penicillin. Nobel Lecture, December 11, 1945.
  4. Centers for Disease Control and Prevention Interagency Task Force on Antimicrobial Resistance. A Public Health Action Plan to Combat Antimicrobial Resistance. Part 1: Domestic Issues. 2001.
  5. Centers for Disease Control and Prevention Interagency Task Force on Antimicrobial Resistance. A Public Health Action Plan to Combat Antimicrobial Resistance. 2011. Accessed October 13, 2011.
  6. World Health Organization. WHO Global Strategy for Containment of Antimicrobial Resistance. 2001.
  7. Andersson DI, Hughes D. Antibiotic resistance and its cost: is it possible to reverse resistance? Nat Rev Microbiol. 2010;8:260-271.
  8. Skalet AH, Cevallos V, Ayele B, et al. Antibiotic selection pressure and macrolide resistance in nasopharyngeal Streptococcus pneumoniae: a cluster-randomized clinical trial. PLos Med. 2010;14:e1000377.
  9. Bergman M, Huikko S, Huovinen P, et al. Macrolide and azithromycin use are linked to increased macrolide resistance in Streptococcus pneumoniae. Antimicrob Agents Chemother. 2006;50:3646-3650.
  10. Pihlajamäki M, Kotilainen P, Kaurila T, et al. Macrolide-resistant Streptococcus pneumoniae and use of antimicrobial agents. Clin Infect Dis. 2001;15:483-488.
  11. Haug S, Lakew T, Habtemariam G, et al. The decline of pneumococcal resistance after cessation of mass antibiotic distributions for trachoma. Clin Infect Dis. 2010;51:571-574.
  12. Gilbert DN, Moellering RC Jr, Eliopoulos GM, et al. The Sanford Guide to Antimicrobial Therapy 2011. 41st ed. Sperryville, VA: Antimicrobial Therapy, Inc.; 2011.
  13. Wynne AL. Drugs used in treating infectious diseases. In: Woo TM, Wynne AL, eds. Pharmacotherapeutics for Nurse Practitioner Prescribers. 3rd ed. Philadelphia, PA: F.A. Davis; 2011:625-744.
  14. Allegranzi B, Pittet D. Role of hand hygiene in healthcare-associated infection prevention. J Hosp Infect. 2009;73:305-315.
  15. Grijalva CG, Nuorti JP, Griffin MR. Antibiotic prescription rates for acute respiratory tract infections in US ambulatory settings. JAMA. 2009;302:758-766.
  16. Gonzales R, Corbett KK, Wong S, et al. “Get smart Colorado”: impact of a mass media campaign to improve community antibiotic use. Med Care. 2008;46:597-605.
  17. Vanderweil SG, Pelletier AJ, Hamedani AG, et al. Declining antibiotic prescriptions for upper respiratory infections, 1993-2004. Acad Emerg Med. 2007;14:366-369.
  18. Miller GE, Hudson J. Children and antibiotics: analysis of reduced use, 1996-2001. Med Care. 2006;44(5 suppl):I36-I44.
  19. Roumie CL, Halasa NB, Grijalva CG. et al. Trends in antibiotic prescribing for adults in the United States—1995-2002. J Gen Intern Med. 2005;20:697-802.
  20. Centers for Disease Control and Prevention. Office-related antibiotic prescribing for persons aged ≤14 years — United States, 1993-1994 to 2007-2008. MMWR Morb Mortal Wkly Rep. 2011;60(34):1153-1156.
  21. Shapiro DJ, Gonzales R, Cabana MD, Hersh AL. National trends in visit rates and antibiotic prescribing for children with acute sinusitis. Pedatrics. 2011;127:28-34.
  22. Roumie CL, Halasa NB, Edwards KM, et al. Differences in antibiotic prescribing among physicians, residents, and nonphysician clinicians. Am J Med. 2005;118:641-648.
  23. Hart AM. Response to differences in antibiotic prescribing. Am J Med. 2006;119:e21-22.
  24. Gonzales R, Barrett PH Jr, Crane LA, Steiner JF. Factors associated with antibiotic use for acute bronchitis. J Gen Intern Med. 1998;13:541-548.
  25. Gonzales R, Steiner JF, Lum A, Barrett PH Jr. Decreasing antibiotic use in ambulatory practice: impact of a multidimensional intervention on the treatment of uncomplicated acute bronchitis in adults. JAMA. 1999;281:1512-1519.
  26. Ladd E. The use of antibiotics for viral upper respiratory tract infections: an analysis of nurse practitioner and physician prescribing practices in ambulatory care, 1997-2001. J Am Acad Nurse Pract. 2005;17:416-424.
  27. White D, Moir A, Zweifler J, Hughes S. Parental satisfaction without antibiotics. Nurse Pract. 2010;35:40-42.
  28. van Duijn HJ, Kuyvenhoven MM, Schellevis FG, Verheij TJ. Illness behaviour and antibiotic prescription in patients with respiratory tract symptoms. Br J Gen Pract. 2007;57:561-568.
  29. Welschen I, Kuyvenhoven M, Hoes A, Verheij TJ. Antibiotics for acute respiratory tract symptoms: patients’ expectations, GPs’ management and patient satisfaction. Fam Pract. 2004;21:234-237.
  30. World Health Organization. WHO Guidelines on Hand Hygiene in Health Care: First Global Patient Safety Challenge — Clean Care is Safer Care. 2009.
  31. Sarkar P, Gould IM. Antimicrobial agents are societal drugs: how should this influence prescribing? Drugs. 2006;66:893-901.
  32. McGowan JE Jr, Gerding DN. Does antibiotic restriction prevent resistance? New Horiz. 1996;4:370-376.
  33. Bosso JA, Drew RH. Application of antimicrobial stewardship to optimise management of community acquired pneumonia. Int J Clin Pract. 2011;65:775-783.
  34. Tamma PD, Cosgrove SE. Antimicrobial stewardship. Infect Dis Clin North Am. 2011;25:245-260.
  35. Centers for Disease Control and Prevention. Get smart: Know when antibiotics work.
  36. Braxton CC, Gerstenberger PA, Cox GG. Improving antibiotic stewardship: order set implementation to improve prophylactic antimicrobial prescribing in the outpatient surgical setting. J Ambul Care Manage. 2010;33:131-140.
  37. Toth NR, Chambers RM, Davis SL. Implementation of a care bundle for antimicrobial stewardship. Am J Health Syst Pharm. 2010;67:746-749.

All electronic documents accessed October 15, 2011.