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Antimicrobial stewardship

Authors
Marisa Holubar, MD, MS
Stan Deresinski, MD
Section Editor
David C Hooper, MD
Deputy Editor
Elinor L Baron, MD, DTMH

INTRODUCTION

Antimicrobial stewardship consists of systematic measurement and coordinated interventions designed to promote the optimal use of antibiotic agents, including their choice, dosing, route, and duration of administration [1]. The primary goal of antibiotic stewardship is to optimize clinical outcomes while minimizing unintended consequences of antibiotic use (including toxicity, selection of pathogenic organisms such as Clostridium difficile, and the emergence of antibiotic resistance) [2]. Additional benefits include improving susceptibility rates to targeted antibiotics and optimizing resource utilization [1].

Antibiotic misuse is widespread and has potentially profound adverse effects [3]. Administration of an antibiotic course to a patient exposes the approximately 1012 bacteria (the microbiome) in that patient to selective pressure, which may alter the intestinal microbiota for as long as a year [4,5]. The United States Centers for Disease Control and Prevention estimated in 2013 that, each year, two million infections caused by antibiotic-resistant pathogens occur in the United States, resulting in 23,000 deaths [6].

In 2016, the United States Centers for Disease Control (CDC) and Centers for Medicare and Medicaid Services (CMS) developed an antibiotic stewardship program that will impact antibiotic prescribers in United States health care facilities that receive CMS funding and/or Joint Commission accreditation. The program is described in a "playbook" that is designed to help facilities implement the CDC Core Elements of Hospital Antibiotic Stewardship Programs [7]. The primary goal is to promote "smart use" of antibiotics in the face of data demonstrating substantial overuse. Measurement of outcomes will be performed by comparing health care facilities of similar size and patient populations. Interventions to achieve this goal are discussed in the following sections.

Effective in 2017, the Joint Commission requires that all hospitals and nursing care centers have antimicrobial stewardship programs [8]. Issues related to hospital-based stewardship are reviewed here. Similar principles may be applied to other settings such as outpatient-based practices and long-term care facilities, as logistics and resources permit [1].

PRINCIPLES OF ANTIBIOTIC USE

In general, management of patients with suspected or proven bacterial infection consists of initiation of empiric therapy (ie, prior to availability of definitive microbiology data), followed by adjustment once microbiology data become available.

                           

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Literature review current through: Nov 2016. | This topic last updated: Fri Nov 11 00:00:00 GMT 2016.
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