Introduction

Antimicrobial resistance is one of the greatest health threats of the 21st century. The current number of deaths attributed to drug-resistant infections is 700,000,¹ yet this figure is expected to grow more than 10-fold by 2050.² Although the rapid administration of antibiotics to treat infections often reduces morbidity and saves the lives of many patients each year, it has also been shown that up to 40% of all antibiotics prescribed are either unnecessary or inappropriate,³ which contributes to the growing problem of antibiotic resistance. Many health care professionals recognize the grave danger of this threat and are implementing measures to slow the evolution of drug-resistant microorganisms. Collectively, these efforts are referred to as antimicrobial stewardship, and many institutions are developing antimicrobial stewardship programs (ASPs). Antimicrobial stewardship promotes the appropriate use of antimicrobials to ultimately decrease the spread of infection caused by multidrug-resistant organisms.

Principles of Antimicrobial Stewardship Programs

Because of the high priority of antimicrobial stewardship, the Centers for Disease Control and Prevention issued recommendations regarding the implementation of programs that outline seven core elements critical to a successful ASP, as described here⁴:

1. Leadership resources: Facilities must consider whether management and senior leadership are ready to identify antimicrobial stewardship as an institutional objective and allocate the appropriate financial and technological support.
2. Accountability/responsibility: ASPs need formal and written strategies that are based on a multidisciplinary approach. A single antimicrobial stewardship leader should be identified, and documentation must be created to convey roles, expectations, and responsibilities for all others.
3. Drug expertise: Facilities should designate a single pharmacist leader who can work on goals to improve the use of antibiotics. On a broader scale, it is also beneficial to have laboratory and imaging staff who can ensure timely results to support the adequate diagnosis of infections.⁵
4. Action: ASPs need a commitment to action; this involves implementing at least one recommended action to improve oversight and assessment of antibiotic use. A common example would be the evaluation of ongoing patient needs after a set period of initial treatment.
5. Monitoring/tracking: Health care facilities should monitor antimicrobial use at a unit-wide and/or hospital-wide level.
6. Reporting: Regular reporting of the monitoring results, antibiotic use, and drug resistance should be provided to all staff, including physicians, nurses, and other interested individuals.
7. Education: Facilities must consider providing ongoing educational and training efforts directed to all support staff on a range of topics geared toward antimicrobial resistance and optimal prescribing practices.

Antimicrobial Stewardship Programs Across a Variety of Settings

Whereas many of these recommendations were crafted with large health care facilities in mind, each of the seven core elements is still necessary for smaller health facilities, although their programs may look very different. Assessments of ASPs at smaller hospitals with limited resources have shown that these institutions face unique challenges, particularly if they have no access to infectious disease consultations. This lack of access often leads to a failure to achieve the necessary buy-in from other physicians on staff. Other obstacles commonly encountered by smaller facilities include⁴:

• Inadequate technological resources related to electronic medical record systems
• Lack of surveillance tools to identify patients for ASP intervention
• Lack of time to assign physician or pharmacist ASP champions
• Insufficient stewardship training for pharmacist leads

Despite these obstacles, successful ASP implementation is often still achieved by small facilities when access to central expertise is provided, often by a clinical pharmacist or an infectious disease specialist. Opening this channel of communication can contribute greatly to overcoming the largest obstacles encountered in the formation of a successful ASP.

Infection Prevention Best Practices for Wound Care

Another key strategy in ASPs is understanding how to promote best practices that will prevent the spread of infection whenever possible. This includes the following actions⁶:

• Proper hand hygiene, including thorough washing and glove use when treating wounds
• Wearing of other personal protective equipment when necessary (e.g., wearing a mask during debridement)
• Single use of sterilized equipment, which should then be re-sterilized after the single use
• Proper disposal of all disposable equipment
• Proper disposal of all dressings or anything else that has come in contact with the wound
• Avoidance of direct contact with the wound bed

Conclusion

Although the implementation of a robust ASP may present challenges for many health care organizations, particularly smaller ones, the endeavor is crucial in reducing the numbers of drug-resistant infections that will be experienced in the future. Best practices for antibiotic stewardship will continue to evolve, but the integration of current recommendations provides a strong step in achieving responsible antibiotic administration.

References

1. McLeod M, Ahmad R, Shebl NA, Micallef C, Sim F, Holmes A. A whole-health-economy approach to antimicrobial stewardship: analysis of current models and future direction. PLoS Med. 2019;16(3):e1002774.

2. United Nations meeting on antimicrobial resistance. Bull World Health Organ. 2016;94(9):633-708.

3. Barlam TF, Soria-Saucedo R, Cabral HJ, Kazis LE. Unnecessary antibiotics for acute respiratory tract infections: association with care setting and patient demographics. Open Forum Infect Dis. 2016;3(1):ofw045.

4. Logan AY, Williamson JE, Reinke EK, Jarrett SW, Boger MS, Davidson LE. Establishing an antimicrobial stewardship across a large, diverse health care system. Jt Comm J Qual Patient Saf. 2019;45(9):591-599.

5. Mendelson M, Morris AM, Thursky K, Pulcini C. How to start an antimicrobial stewardship programme in a hospital [E-pub ahead of print August 22, 2019]. Clin Microbiol Infect. doi: 10.1016/j.cmi.2019.08.007.

6. Minnesota Department of Health. Wound care infection prevention recommendations for long-term care facilities. 2018. https://www.health.state.mn.us/facilities/patientsafety/infectioncontro…. Accessed November 5, 2019.