Antimicrobial Stewardship

Chief Advisor(s): Michael A.E. Ramsay, MD, FRCA
Publication ID: 8743195620
Published on: September 2023
Major Revision: May 24, 2024

Overview

Studies show 30% of antibiotic prescriptions (47 million) per year in the US alone are unnecessary and directly contribute to antibiotic resistance, resulting in approximately 700,000 deaths. Experts estimate that by 2050 antibiotic resistance-related deaths will exceed 10 million globally, at a financial cost of $100 trillion. Antimicrobials are the only medicines where use in one patient can affect how well that medicine works in another patient. The Centers for Medicare and Medicaid Services and the Joint Commission now require facilities to have a formal Antimicrobial Stewardship Program in place to promote appropriate and judicious use of antimicrobials as a key part of patient safety. This blueprint outlines the actionable steps healthcare organizations should take to successfully improve antimicrobial use and summarizes the available evidence-based practice protocols.

Frontline staff

Unit Managers

Hospital Executives

Patient & Families

Resources

Frontline staff

This blueprint outlines the steps that frontline staff can follow to improve antimicrobial stewardship:

Best Practice Summary

  1. Assess the patient’s individual history and their antimicrobial use.
  2. Identify high-risk patients through multifactorial risk assessment tools.
  3. Use diagnostic tests to determine pathogenic etiology and make treatment recommendations.
  4. Determine whether the patient’s condition would be most appropriately treated with antibiotics.
  5. Discuss patient’s expectations for their appointment to avoid disappointment if antibiotics are not prescribed.
  6. Communicate effectively with patients about when and why antibiotics are used.
  7. Thoroughly review the type of antimicrobial the patient has received and explain the reasons why that particular treatment option was chosen.
  8. Educate the patient on how to properly store and administer the antimicrobial.
  9. Educate the patient about preventing the spread of contagious pathogens, infection control, and secondary bacterial infections.
  10. Examine trends in antimicrobial use and other related process and outcome metrics.

Clinical Workflow

  1. Initial assessment
    1. Understand patient complaints and history of infection, antimicrobial use, and C. difficile.
    2. Assess for signs of sepsis.
  2. Prescribing conditions
    1. Use a diagnostic test to support the decision to use antimicrobials and to escalate or deescalate treatment by examining the pathogen, patient’s response to antimicrobial treatment(s), antimicrobial susceptibility, and resistance markers.
    2. Confirm viral, fungal, or bacterial etiology.
    3. “Rule out” bacterial infections to support a decision to not treat with antibiotics instead of pursuing a “rule in” method.
    4. Help the patient understand why they are not receiving antibiotics, if applicable. Often, patients expect to receive some form of prescription, and without hearing why they aren’t receiving one, patients may leave dissatisfied.
    5. Determine if public health officials should be informed.
  3. Post-prescribing
    1. Help the patient understand how to properly store and take the antimicrobials at home.
    2. Educate patients on infection control to prevent the spread of contagious pathogens.
    3. Educate patients on available vaccines for conditions that can contribute to secondary bacterial infections (influenza, pneumonia, etc.).

Education for Patients, Caregivers, and Family Members

  1. If antibiotics are not indicated, explain to the patient and family members or caregivers why. Often, patient satisfaction can be linked to a prescription, and if they do not receive a prescription, they may feel as though their care was inadequate unless they receive an explanation.
  2. Additionally, let family members and caregivers know exactly when to call for help, where to go for help, and with whom they should speak. It is essential that patients and family members and caregivers understand that they should not be ashamed to ask any of their questions and that many patients in similar situations often have similar questions.
  3. Instead of issuing a directive conversation style, have an active, engaging conversation with patients and family members that leaves opportunities for questions and repeat-back strategies. When patients and family members understand the signs and symptoms of a potential problem, they can serve as an extra set of eyes in order to elevate this concern as early as possible.
  4. Describe what can be anticipated. If antimicrobials are indicated, explain what the patient can expect in terms of side effects, resolution of symptoms, and the duration of treatment, assuming they take the antimicrobials as instructed.
  5. Prepare family members and caregivers through conversations about what to do if a problem arises so they will understand where to go to find out more information about their loved one’s infection or condition.
  6. Explain what is expected of them during their care. By giving patients and family members a “job” while they are in the hospital, they can be immersed fully in the routine care, can hold other team members accountable, can feel more confident voicing their concerns or opinions, and can serve as an extra set of informed and vigilant eyes to prevent deterioration and further infection. This team involvement can also reduce their anxiety by transforming concern into proactive action.
Unit Managers

This guide outlines the steps that unit managers can follow to improve antimicrobial stewardship:

Use this checklist as a guide to determine whether current evidence-based guidelines are being followed in your organization.

  1. Measure process and outcome metrics on an ongoing basis to identify areas for improvement.
    1. Measure and report antimicrobial use monthly (Days of therapy of antibiotics/1,000 patient days).
    2. Note trends in areas with high broad-spectrum antibiotic use and high antibiotic resistance. Routinely reassess outcomes.
  2. Establish an antimicrobial stewardship program and align it with other organizational activities for greatest impact.
    1. Consider pros and cons of restrictive and prospective antimicrobial stewardship programs.
    2. Identify goals of the committee, which may include:
      1. Decreasing inappropriate use of antibiotics
      2. Identifying and reducing risks of developing, acquiring, and transmitting infections
      3. Reducing healthcare costs and toxicities with antimicrobials and inappropriate therapy
      4. Preventing adverse drug events
    3. Improving specific patient outcomes (e.g., reducing C. difficile rates)
    4. Publish facility-specific guidelines that include recommendations for diagnostic and testing approaches and common indications for antibiotic use.
    5. Ensure that antimicrobial stewardship protocols are embedded in clinical workflows, whether electronic or paper.
    6. Clarify clinical indication for antibiotic use and ensure these guidelines are readily available for the frontline.
    7. Ensure adequate training and documentation of antimicrobial stewardship competencies and skills.
    8. Use Computerized Provider Order Entry (CPOE) with Clinical Decision Support (CDS) and computer-based surveillance software to provide real-time data at the point of care for Antimicrobial Stewardship Program initiatives.
    9. Develop and disseminate educational materials for judicious antibiotic prescription and align these educational activities with other related educational activities across the organization for optimal impact.
    10. Create pharmacy-driven protocols, which may include:
      1. Establishing clinical stability criteria for changes from intravenous (IV) to oral (PO) antibiotic therapy
      2. Standardizing adjustment of antimicrobial dosage in cases of organ dysfunction
      3. Optimizing dose (pharmacokinetics/pharmacodynamics) to treat organisms with reduced susceptibility
      4. Implementing time-sensitive automatic stops to orders for specific antibiotic prescriptions
    11. Create microbiology lab-driven protocols, which may include:
      1. Implementing rapid diagnostics, such as Multiplex PCR or Matrix Assisted laser desorption/ionization-time of flight (MALDI-TOF)
      2. Standardizing procalcitonin level measurement
      3. Reporting minocycline susceptibility for Acinetobacter isolates
    12. Establish audit and feedback measures.
    13. Ensure that leaders have a simple process to oversee antimicrobial stewardship improvement work while also considering how it aligns with other initiatives across the organization.
    14. Involve patients and those on the frontline in improvement initiatives.
      1. Ensure frontline involvement in antimicrobial stewardship improvement activities. Maintain their engagement and remove barriers to progress.
      2. Involve patient advocates and members of the Patient and Family Advisory Council (PFAC) in identifying barriers to patient antibiotic adherence and proper storage and disposal.
      3. Ensure there are enough staff to effectively manage necessary care.
      4. Educate frontline staff on antimicrobial stewardship initiatives and progress.
      5. Debrief on a regular basis to solicit team feedback about barriers to sustained compliance. Adjust the plan quickly and nimbly as needed.
      6. Hold staff accountable for providing the standard of care and reward success.

Performance Improvement Plan

  1. Gather the right project team.
  2. Form two teams:
    1. An oversight team that is broad in scope, has 10–15 members, and includes the executive sponsor to validate outcomes, remove barriers, and facilitate spread.
    2. The actual project team that consists of 5–7 representatives who are most impacted by the process.
    3. Whether a discipline should be on the advisory team or the project team depends upon the needs of the organization.
    4. Patients and family members should be involved in all improvement projects, as there are many ways they can contribute to safer care.
  3. Understand what is currently happening and why.
    1. Reviewing objective data and trends is a good place to start to understand the current state, and teams should spend a good amount of time analyzing data (and validating the sources), but the most important action here is to go to the point of care and observe.
    2. Even if team members work in the area daily, examining existing processes from every angle is generally an eye-opening experience. The team should ask questions of the frontline during the observations that allow them to understand each step in the process and identify the people, supplies, or other resources needed to improve patient outcomes.
  4. Prioritize the gaps to be addressed and develop an action plan.
  5. Consider the cost effectiveness, time requirements, potential outcomes, and realistic possibilities of addressing each gap identified.
  6. Determine which are priorities of focus for the organization.
    1. Be sure that the advisory team supports moving forward with the project plan so they can continue to remove barriers.
  7. Design an experiment to be trialed in one small area for a short period of time and create an action plan for implementation.
  8. Evaluate outcomes, celebrate wins, and adjust the plan when necessary.
  9. Measure both process and outcome metrics.
    1. Outcome metrics include the rates outlined below.
    2. Process metrics will depend upon the workflow you are trying to improve and are generally expressed in terms of compliance with workflow changes.
    3. Compare your outcomes against other related metrics your organization is tracking.
  10. Routinely review all metrics and trends with both the advisory and project teams and discuss what is going well and what is not.
  11. Identify barriers to completion of action plans and adjust the plan if necessary.
  12. Once you have the desired outcomes in the trial area, consider spreading to other areas.
  13. Be nimble and move quickly to keep team momentum going, and so that people can see the results of their labor. At the same time, don’t move so quickly that you don’t consider the larger, organizational ramifications of a change in your plan.
  14. Be sure to have a good understanding of the other, similar improvement projects that are taking place so that your efforts are not duplicated or inefficient.

The action plan should include the following steps:

  1. Assess the ability of the culture to change and adopt appropriate strategies.
  2. Revise policies and procedures.
  3. Redesign forms and electronic record pages.
  4. Clarify patient and family education sources and content.
  5. Create a plan for changing documentation forms and systems.
  6. Develop the communication plan.
  7. Design the education plan.
  8. Clarify how and when people will be held accountable.

Antibiotic administration processes to consider assessing:

  1. Assessment of prior C. diff infection
  2. Assessment of prior antibiotics or recent hospitalization
  3. Review of antibiotic therapy 2–3 days after initiation based on the patient’s clinical lab data
  4. Patient education

Typical gaps identified in antibiotic stewardship:

  1. There is pressure to prescribe antibiotics based on financial incentives.
  2. There is pressure to prescribe antibiotics based on patient satisfaction.
  3. Antibiotic administration guidelines are updated and not communicated effectively.
  4. Duration and frequency of use guidelines are not known or used upon prescribing.
  5. Antibiotics are not stored or disposed of properly.
  6. Antibiotics are overused in the virtual setting.
  7. Whether the infection is viral or bacterial is not known at the time of prescribing.
  8. Providers do not have a full understanding of the patient’s previous antimicrobial use and infection history.

Recommended antimicrobial stewardship improvement team:

  1. Infection preventionists
  2. Pharmacists
  3. Information technologists
  4. Quality and safety specialists
  5. Nurses
  6. Providers
  7. Microbiologists
  8. Sepsis improvement teams
  9. Primary care providers
  10. Outpatient specialists
  11. Emergency medicine providers
  12. Urgent care providers
  13. Dentists
  14. Admitting and registration staff

Antimicrobial stewardship metrics to consider assessing:

  1. Length of stay
  2. Readmission
  3. Sepsis
  4. Resistance patterns among microorganisms
  5. Outcomes associated with changes in antibiotic use
  6. Defined daily doses
  7. Days of therapy (DOT) of antibiotics per 1,000 patient days
  8. Clostridium difficile infections (CDI)
  9. Providers with excessive prescribing habits
Hospital Executives

This protocol outlines the steps that hospital executives can follow to improve antimicrobial stewardship:

It has been shown that 30% of antibiotic prescriptions (47 million) per year in the US alone are unnecessary and directly contribute to antibiotic resistance. Approximately 700,000 deaths worldwide are the direct result of antimicrobial resistant infections, and it is estimated that by 2050, there will be 10 million antibiotic resistance-related deaths globally, corresponding to a price of $100 trillion. In Europe, 25,000 patients annually die from multidrug-resistant bacterial infections, which also result in losses of at least €1.5 billion per year. It has been estimated that a 30% reduction in broad-spectrum antibiotics  prescribed for patients in the hospital and upon discharge (which would contribute to a 5% decrease in antibiotic use overall) would be correlated with a nearly 30% decrease in Clostridioides difficile infection alone. Antimicrobial resistance is estimated to add $1,383 per patient, culminating in $2.2 billion in excess costs annually.

Antimicrobials are the only medicines where use in one patient can affect how well that medicine works in another patient. Antimicrobial stewardship includes efforts to promote the appropriate use of antimicrobials, including antibiotics, to prevent:

  1. Spread of infections
  2. Adverse reactions and adverse drug events
  3. Superinfections
  4. Infections that are resistant to antimicrobials
  5. Poor clinical outcomes

Hospital executives can significantly help with proper prescription and use of antimicrobial agents at their facilities by doing the following:

  1. Implement an antimicrobial stewardship initiative.
  2. Evaluate the advantages and disadvantages of both restrictive and prospective approaches to antimicrobial stewardship programs.
  3. Establish clear antimicrobial stewardship protocols.
  4. Provide accessible educational materials on antimicrobial stewardship for all staff members.
  5. Allocate adequate resources for auditing the antimicrobial stewardship program.
  6. Engage patients in antimicrobial stewardship efforts.
  7. Ensure sufficient staffing to integrate the antimicrobial stewardship program effectively.
  8. Enforce accountability within the management team for integrating the antimicrobial stewardship program.
Patient & Families

This guide outlines the steps that patients and family members can follow to support antimicrobial stewardship: 

Antimicrobial stewardship refers to a coordinated effort to optimize the use of antimicrobial agents, including antibiotics, antivirals, antifungals, and antiparasitics, with the goal of improving patient outcomes, ensuring the most effective treatment of infections, reducing adverse effects, and combating antibiotic resistance.

Patients, family members, and caregivers should take the following steps to ensure the proper use of antimicrobial agents (e.g., antibiotics) and help impede the development of antimicrobial resistance:

  1. Ask about antimicrobial resistance.
  2. Understand what type of infection the antimicrobial agent will treat.
  3. Understand how long the antimicrobial agents are needed, how to properly take the antibiotics, and what types of side effects may be expected.
  4. Disclose if the patient has recently taken other antimicrobial agents or has been in another healthcare facility recently.
  5. Inquire about hospital protocols to prevent infection, especially Clostridioides difficile (C. Diff) and MRSA (Methicillin-resistant Staphylococcus aureus).
  6. Stay updated on flu and pneumonia vaccinations.
  7. Ask your healthcare team if antimicrobial agents are needed to treat your condition.
  8. Use antimicrobials only as directed by the prescriber.
  9. Make sure to keep antimicrobials secure and do not share them.
  10. Engage in conversations around current potential health conditions.
  11. Ask about hospital’s antimicrobial resistance protocols.
  12. Monitor hand hygiene of all healthcare providers and visitors.
  13. Watch for any signs of the patient declining.
Resources

American Society for Microbiology.  CMS Final Rule on Antibiotic Stewardship Programs. (2019)
https://asm.org/Articles/Policy/2019/CMS-Final-Rule-on-Antibiotic-Stewardship-Programs#%3A~%3Atext%3DThe%20rule%20requires%20all%20acute%2Cof%20their%20infection%20control%20efforts

Baker D, et al. Leading Practices in Antimicrobial Stewardship: Conference Summary. (2019)
https://www.sciencedirect.com/science/article/pii/S1553725019300522?casa_token=L7Ekmd-36O4AAAAA:RdxG4aw8g0RXECKE5nahxJYaoJqyCq-_lC-30TP73JCiZFty8-IyFDAtddQzW4KttL-EE-g8gr_W

Centers for Disease Control and Prevention. Antibiotic-resistant Germs: New Threats. (2020)
https://www.cdc.gov/drugresistance/biggest-threats.html

Center for Disease Control and Prevention.  Antibiotic / Antimicrobial Resistance (AR / AMR). (2020)
https://www.cdc.gov/drugresistance/

Massimo S, et al. Ten golden rules for optimal antibiotic use in hospital settings: the WARNING call to action. (2023)
https://wjes.biomedcentral.com/articles/10.1186/s13017-023-00518-3

May L, et al. Antimicrobial stewardship in the emergency department: characteristics and evidence for effectiveness of interventions. (2021)
https://www.sciencedirect.com/science/article/pii/S1198743X20306595

World Health Organization. Antibiotic resistance. (2020)
https://www.who.int/news-room/fact- sheets/detail/antibiotic-resistance

World Health Organization. Antimicrobial stewardship interventions: a practical guide. (2021)
https://apps.who.int/iris/handle/10665/340709

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