Antibiotic stewardship is an evolving concept of ensuring the proper usage of antibiotics in order to combat the growing problem of antimicrobial resistance observed. Methods of implementing programs have often involved informatics modalities.
What is Antimicrobial Stewardship?
The Infectious Diseases Society of America (IDSA) together with the Pediatrics Infectious Disease Society and the Society for Healthcare Epidemiology of America define antimicrobial stewardship as “coordinated interventions designed to improve and measure the appropriate use of antimicrobial agents by promoting the selection of the optimal antimicrobial drug regimen including dosing, duration of therapy, and route of administration. The major objectives of antimicrobial stewardship are to achieve best clinical out-comes related to antimicrobial use while minimizing toxicity and other adverse events, thereby limiting the selective pressure on bacterial populations that drives the emergence of antimicrobial-resistant strains. Antimicrobial stewardship may also reduce excessive costs attributable to suboptimal antimicrobial use.”
This has become vital in the modern era where the emergence of superbugs, resistant to all our conventional antibiotics have emerged. This emergence has been so rapid that drug development has not been able to keep pace with resistance. There has been an increasing amount of incidences where untreatable infections have emerged .
Stewardship programs take a variety of different approaches across the world. Examples include a restricted drug list, where only certain clinicians (such as infectious disease physicians) are allowed to prescribe certain antibiotics, a system of automatic review of certain antimicrobial use by antibiotic stewardship practitioners, and automatic flags for reassessment for necessity of drugs. Additionally, a mandate by these programs is also to track the actual usage of antibiotics in the hospital setting.
With the advent of clinical informatics and the modernization of the electronic medical record, various opportunities have arisen to incorporate the two fields for better outcomes. For instance, the IDSA has released guidelines suggesting the implementation of clinical decision support systems for stewardship whenever possible . Other examples are the gathering of laboratory data to form biograms, often available online, to demonstrate local resistance patterns , mobile and desktop apps for clinicians, and the use of social media to spread discussion regarding stewardship.
Examples of Stewardship and Informatics Applications:
Mobile Apps: Various apps have been developed and used by clinicians to improve their antibiotic usage including: 1)UptoDate (https://www.uptodate.com/home) 2)Spectrum (https://cumming.ucalgary.ca/ermedicine/resources/spectrum-calgary-zone-antimicrobial-stewardship) 3)Bugs and Drugs (http://www.dobugsneeddrugs.org/health-care-professionals/bugs-drugs-antimicrobial-reference/) 4)Sanford Guide (https://www.sanfordguide.com/)
Clinical Decision Support Systems:
With the advent of computerized provider order entry, many systems have implemented methods of improving stewardship with CDSS. This has taken many forms including alerts or restrictions for certain antimicrobials. Alerts could be customized or information given based on local practice patterns, clinicians may be forced to select certain criteria for the use of specific antibiotics, there could be criteria for use of certain antibiotics, order sets, treatment algorithms, or dosage suggestions. Additionally, many of these systems also alert the antimicrobial stewardship team on certain factors such as the use of restricted agents, patients being on antibiotics for certain amounts of time, results of cultures, swapping patients to oral antibiotics, and inappropriate therapy for certain pathogens.
1.Fishman N et al. Policy Statement on Antimicrobial Stewardship by the Society of Healthcare Epidemiology of America (SHEA), the Infectious Diseases Society of America (IDSA), and the Pediatric Infectious Diseases Society (PIDS). Infect Control Hosp Epidemiol. April 2012. 33(4):322-7
2.CBC. How this couple used a bacteria-fighting virus to thwart a deadly superbug. Accessed from: https://www.cbc.ca/radio/thecurrent/the-current-for-march-4-2019-1.5041453/how-this-couple-used-a-bacteria-fighting-virus-to-thwart-a-deadly-superbug-1.5041457
3.Barlam TF et al. Implementing an Antibiotic Stewardship Program: Guideliens by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. Clinical Infectious Diseases. May 2016. 62(10):e51-e77.
4.Saskatchewan Health Authority. Antibiograms. Accessed from: http://www.rqhealth.ca/department/laboratory-services/Antibiograms
Submitted by (Stephen Lee)