The Current State of Antimicrobial Stewardship: Challenges, Successes, and Future Directions

Current Infectious Disease Reports

Volumn 20, Issue 9, 2018, Pages

  Emberger, Jennifer ^a   Tassone, Dan ^b   Stevens, Michael P ^a   Markley, J Daniel ^a  

^a VIRGINIA COMMONWEALTH UNIVERSITY MEDICAL CENTER   (United States)

^b VETERANS AFFAIRS MEDICAL CENTER   (United States)

Author keywords

Antimicrobial stewardship; Antimicrobial stewardship metrics; Antimicrobial utilization; Diagnostic test stewardship; Rapid diagnostics; Telemedicine

Indexed keywords

ANTIBIOTIC AGENT;

ALLERGY TEST; ANTIBIOTIC RESISTANCE; ANTIBIOTIC SENSITIVITY; ANTIMICROBIAL STEWARDSHIP; AWARENESS; BLOODSTREAM INFECTION; CLINICAL DECISION MAKING; CLOSTRIDIUM DIFFICILE INFECTION; COMMUNITY ACQUIRED PNEUMONIA; DRUG COST; DRUG EFFICACY; DRUG HYPERSENSITIVITY; DRUG SAFETY; EXPECTATION; FUNDING; HEALTH CARE ACCESS; HEALTH CARE COST; HEALTH CARE POLICY; HEALTH CARE UTILIZATION; HEPATITIS C; HOSPITAL INFECTION; HOSPITAL MORTALITY; HUMAN; HUMAN IMMUNODEFICIENCY VIRUS INFECTION; INCIDENCE; INFECTION RATE; LENGTH OF STAY; MATRIX ASSISTED LASER DESORPTION IONIZATION TIME OF FLIGHT MASS SPECTROMETRY; MEDICAID; MEDICARE; POLYMERASE CHAIN REACTION; PRESCRIPTION; PROTOCOL COMPLIANCE; REIMBURSEMENT; REVIEW; SEPSIS; SKIN INFECTION; SOFT TISSUE INFECTION; TELEHEALTH; TREATMENT OUTCOME; TUBERCULOSIS; URINARY TRACT INFECTION;

EID: 85049214006     PISSN: 15233847     EISSN: 15343146     Source Type: Journal    
DOI: 10.1007/s11908-018-0637-6     Document Type: Review

References (78)

1. CDC. Antibiotic Resistance Threats in the United States. 2013. Available at https://www.cdc.gov/drugresistance/pdf/ar-threats-2013-508.pdf.
2. WHO. Global Action Plan on antimicrobial resistance. Geneva: World Health Organization; 2015.
3. Klein EY, Van Boeckel TP, Martinez EM, et al. Global increase and geographic convergence in antibiotic consumption between 2000 and 2015. Proc Natl Acad Sci USA. 2018;115(15):E3463–70.
4. McGowan JE, Gerding DN. Does antibiotic restriction prevent resistance? New Horiz. 1996;4(3):370–6.
5. •• Task Force for Combating Antibiotic-Resistant Bacteria. National Action Plan for Combating Antibiotic Resistant Bacteria The White House. 2015. Key policy that stimulated CMS and TJC changes.
6. The Joint Commission. Approved: new antimicrobial stewardship standard. Joint Commission Perspectives. 2016;36(7). https://www.jointcommission.org/assets/1/6/New_Antimicrobial_Stewardship_Standard.pdf.
7. Dellit TH, Owens RC, McGowan JE, et al. Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clin Infect Dis. 2007;44(2):159–77.
8. •• Barlam TF, Cosgrove SE, Abbo LM, MacDougall C, Schuetz AN, Septimus EJ, et al. Implementing an antibiotic stewardship program: guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. Clin Infect Dis. 2016;62(10):e51–77. Key guideline for developing an ASP in the U.S.
9. •• CDC. Core Elements of Hospital Antibiotic Stewardship Programs. Atlanta, GA: US Department of Health and Human Services, CDC; 2014. Available at http://www.cdc.gov/getsmart/healthcare/implementation/core-elements.html. Key recommendations outlining basic components of an ASP.
10. Bernard S, Pakyz A, Kuper K, Nguyen N, Stevens M. How ready are hospitals to meet the centers for Medicare and Medicaid antibiotic stewardship requirements? Open Forum Infectious Diseases. 2016;3(1):968.
11. Fleming-Dutra KE, Hersh AL, Shapiro DJ, Bartoces M, Enns EA, File TM Jr, et al. Prevalence of inappropriate antibiotic prescriptions among US ambulatory care visits, 2010-2011. JAMA. 2016;315(17):1864–73.
12. Suda KJ, Hicks LA, Roberts RM, Hunkler RJ, Danziger LH. A national evaluation of antibiotic expenditures by healthcare setting in the United States, 2009. J Antimicrob Chemother. 2013;68(3):715–8.
13. Sanchez GV, Fleming-Dutra KE, Roberts RM, Hicks LA. Core elements of outpatient antibiotic stewardship. MMWR Recomm Rep 2016;65(No. RR-6):1–12.
14. CDC. Antibiotic prescribing and use in doctor's offices. 2017; https://www.cdc.gov/antibiotic-use/community/index.html.
15. Drekonja DM, Filice GA, Greer N, Olson A, MacDonald R, Rutks I, et al. Antimicrobial stewardship in outpatient settings: a systematic review. Infect Control Hosp Epidemiol. 2015;36(2):142–52.
16. Arnold SR, Straus SE. Interventions to improve antibiotic prescribing practices in ambulatory care. Cochrane Database Syst Rev. 2005;4:CD003539.
17. McDonagh M, Peterson K, Winthrop K, et al. Improving antibiotic prescribing for uncomplicated acute respiratory tract infections. Comparative Effectiveness Review No 163. 2016 (AHRQ Publication No. 15). www.effectivehealthcare.ahrq.gov/reports/final.cfm.
18. Ranji SR, Steinman MA, Shojania KG, Gonzales R. Interventions to reduce unnecessary antibiotic prescribing: a systematic review and quantitative analysis. Med Care. 2008;46(8):847–62.
19. AAMC. Number of Active Physicians in the Largest Specialties by Major Professional Activity, 2015. AMA Physician Masterfile 2015. Available at https://www.aamc.org/data/workforce/reports/458480/1-1-chart.html.
20. George Washington University Health Workforce Institute. Analysis of the NRMP-SMS match for infectious disease for 2016–17 appointment year and trends over-time. 2016.
21. Bonura EM, Lee ES, Ramsey K, Armstrong WS. Factors influencing internal medicine resident choice of infectious diseases or other specialties: a national cross-sectional study. Clin Infect Dis. 2016;63(2):155–63.
22. •• Gauthier TP, Worley M, Laboy V, Hernandez L, Unger NR, Sherman EM, et al. Clinical infectious diseases pharmacists in the United States: a problem of both supply and demand. Clin Infect Dis. 2015;60(5):826–7. Provides insight into workforce shortages.
23. Goff DA, Kullar R, Bauer KA, File TM. Eight habits of highly effective antimicrobial stewardship programs to meet the joint commission standards for hospitals. Clin Infect Dis. 2017;64(8):1134–9.
24. IDSA. Antimicrobial Stewardship Centers of Excellence 2018; http://www.idsociety.org/ascoe/.
25. Boucher HW, Murray BE, Powderly WG. Proposed U.S. funding cuts threaten progress on antimicrobial resistance. Ann Intern Med. 2017;167(10):738–9.
26. Dall C. IDSA slams proposed budget cuts to AMR programs Center for Infectious Disease Research and Policy News. 2017. http://www.cidrap.umn.edu/news-perspective/2017/09/idsa-slams-proposed-budget-cuts-amr-programs.
27. Auwaerter P. Public Health, Biomedical research priorities recognized in FY 2018 funding bill: IDSA statement. In: IDSA; 2018. Available at http://www.idsociety.org/IDSA_appreciates_recognition_of_public_health_2C_biomedical_research_priorities_in_FY_2018_funding_bill.aspx.
28. • Moehring RW, Anderson DJ, Cochran RL, Hicks LA, Srinivasan A, Dodds Ashley ES, et al. Expert consensus on metrics to assess the impact of patient-level antimicrobial stewardship interventions in acute-care settings. Clin Infect Dis. 2017;64(3):377–83. Most important, recent recommendations for currently utilizing and developing new ASP metrics.
29. Maragakis LL, Perencevich EN, Cosgrove SE. Clinical and economic burden of antimicrobial resistance. Expert Rev Anti-Infect Ther. 2008;6(5):751–63.
30. Morris AM, Brener S, Dresser L, Daneman N, Dellit TH, Avdic E, et al. Use of a structured panel process to define quality metrics for antimicrobial stewardship programs. Infect Control Hosp Epidemiol. 2012;33(5):500–6.
31. Society for Healthcare Epidemiology of America, Infectious Diseases Society of America, Pediatric Infectious Diseases Society. Policy statement on antimicrobial stewardship by the Society for Healthcare Epidemiology of America (SHEA), the Infectious Diseases Society of America (IDSA), and the Pediatric Infectious Diseases Society (PIDS). Infect Control Hosp Epidemiol. 2012;33(4):322–7.
32. WHO. Defined Daily Dose. 2018; http://www.who.int/medicines/regulation/medicines-safety/toolkit_ddd/en/.
33. CDC. Antimicrobial Use and Resistance (AUR) Module. 2018. Available at https://www.cdc.gov/nhsn/pdfs/pscmanual/11pscaurcurrent.pdf.
34. Premier. Be Ready. Antimicrobial Use and Resistance (AUR) Reporting to NHSN. In: 2017. Available at http://offers.premierinc.com/rs/381-NBB-525/images/Advisor%20Live_AUR_FINAL_053117.pdf.
35. •• Davey P, Marwick CA, Scott CL, et al. Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database Syst Rev. 2017;2:CD003543. Most recent systematic review of the effectiveness of ASP strategies.
36. • Kelly AA, Jones MM, Echevarria KL, Kralovic SM, Samore MH, Goetz MB, et al. A report of the efforts of the veterans health administration national antimicrobial stewardship initiative. Infect Control Hosp Epidemiol. 2017;38(5):513–20. Best example of the effectiveness of centralized implementation AS across a large health system.
37. Davey P, Brown E, Charani E, et al. Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database Syst Rev. 2013(4):Cd003543.
38. Mehta JM, Haynes K, Wileyto EP, Gerber JS, Timko DR, Morgan SC, et al. Comparison of prior authorization and prospective audit with feedback for antimicrobial stewardship. Infect Control Hosp Epidemiol. 2014;35(9):1092–9.
39. Tamma PD, Avdic E, Keenan JF, Zhao Y, Anand G, Cooper J, et al. What is the more effective antibiotic stewardship intervention: Preprescription authorization or Postprescription review with feedback? Clin Infect Dis. 2017;64(5):537–43.
40. Bond CA, Raehl CL. Clinical and economic outcomes of pharmacist-managed aminoglycoside or vancomycin therapy. Am J Health Syst Pharm. 2005;62(15):1596–605.
41. Momattin H, Zogheib M, Homoud A, Al-Tawfiq JA. Safety and outcome of pharmacy-led vancomycin dosing and monitoring. Chemotherapy. 2016;61(1):3–7.
42. Park SM, Kim HS, Jeong YM, Lee JH, Lee E, Lee E, et al. Impact of intervention by an antimicrobial stewardship team on conversion from intravenous to oral fluoroquinolones. Infect Chemother. 2017;49(1):31–7.
43. Pasquale TR, Trienski TL, Olexia DE, Myers JP, Tan MJ, Leung AK, et al. Impact of an antimicrobial stewardship program on patients with acute bacterial skin and skin structure infections. Am J Health Syst Pharm. 2014;71(13):1136–9.
44. Brumley PE, Malani AN, Kabara JJ, Pisani J, Collins CD. Effect of an antimicrobial stewardship bundle for patients with Clostridium difficile infection. J Antimicrob Chemother. 2016;71(3):836–40.
45. Ohashi K, Matsuoka T, Shinoda Y, Fukami Y, Shindoh J, Yagi T, et al. Evaluation of treatment outcomes of patients with MRSA bacteremia following antimicrobial stewardship programs with pharmacist intervention. Int J Clin Pract. 2018;72:e13065.
46. CDC. Antibiotic resistance patient safety atlas. https://gis.cdc.gov/grasp/PSA/.
47. Duke University School of Medicine. DASON - Duke antimicrobial stewardship outreach network. 2014–2018; https://dason.medicine.duke.edu/.
48. Madden GR, Weinstein RA, Sifri CD. Diagnostic stewardship for healthcare-associated infections: opportunities and challenges to safely reduce test use. Infect Control Hosp Epidemiol. 2018;39(2):214–8.
49. Frazee BW, Enriquez K, Ng V, Alter H. Abnormal urinalysis results are common, regardless of specimen collection technique, in women without urinary tract infections. J Emerg Med. 2015;48(6):706–11.
50. Pallin DJ, Ronan C, Montazeri K, Wai K, Gold A, Parmar S, et al. Urinalysis in acute care of adults: pitfalls in testing and interpreting results. Open Forum Infect Dis. 2014;1(1):ofu019.
51. Sloane PD, Kistler CE, Reed D, Weber DJ, Ward K, Zimmerman S. Urine culture testing in community nursing homes: gateway to antibiotic overprescribing. Infect Control Hosp Epidemiol. 2017;38(5):524–31.
52. Cheung A, Karmali G, Noble S, Song H. Antimicrobial stewardship initiative in treatment of urinary tract infections at a rehabilitation and complex continuing care hospital. Can J Hosp Pharm. 2017;70(2):144–9.
53. Naik AD, Skelton F, Amspoker AB, Glasgow RA, Trautner BW. A fast and frugal algorithm to strengthen diagnosis and treatment decisions for catheter-associated bacteriuria. PLoS One. 2017;12(3):e0174415.
54. Chen S, Gu H, Sun C, Wang H, Wang J. Rapid detection of Clostridium difficile toxins and laboratory diagnosis of Clostridium difficile infections. Infection. 2017;45(3):255–62.
55. McDonald LC, Gerding DN, Johnson S, et al. Clinical practice guidelines for Clostridium difficile infection in adults and children: 2017 update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA). Clin Infect Dis. 2018;66(7):987–94.
56. Olans RN, Olans RD, DeMaria A. The critical role of the staff nurse in antimicrobial stewardship--unrecognized, but Already There. Clin Infect Dis. 2016;62(1):84–9.
57. CDC, American Nurses Association. White paper—redefining the antibiotic stewardship team:recommendations from the American Nurses Association/Centers for Disease Control and Prevention workgroup on the role of registered nurses in hospital antibiotic stewardship practices. 2017. Available at https://www.cdc.gov/antibiotic-use/healthcare/pdfs/ANA-CDC-whitepaper.pdf.
58. Minejima E, Wong-Beringer A. Implementation of rapid diagnostics with antimicrobial stewardship. Expert Rev Anti-Infect Ther. 2016;14(11):1065–75.
59. Perez KK, Olsen RJ, Musick WL, et al. Integrating rapid diagnostics and antimicrobial stewardship improves outcomes in patients with antibiotic-resistant gram-negative bacteremia. J Inf Secur. 2014;69(3):216–25.
60. Suzuki H, Hitomi S, Yaguchi Y, Tamai K, Ueda A, Kamata K, et al. Prospective intervention study with a microarray-based, multiplexed, automated molecular diagnosis instrument (Verigene system) for the rapid diagnosis of bloodstream infections, and its impact on the clinical outcomes. J Infect Chemother. 2015;21(12):849–56.
61. Schuetz P, Wirz Y, Sager R, et al. Procalcitonin to initiate or discontinue antibiotics in acute respiratory tract infections. Cochrane Database Syst Rev. 2017;10:CD007498.
62. Sager R, Kutz A, Mueller B, Schuetz P. Procalcitonin-guided diagnosis and antibiotic stewardship revisited. BMC Med. 2017;15(1):15.
63. Parmar P, Mackie D, Varghese S, Cooper C. Use of telemedicine technologies in the management of infectious diseases: a review. Clin Infect Dis. 2015;60(7):1084–94.
64. Siddiqui J, Herchline T, Kahlon S, Moyer KJ, Scott JD, Wood BR, et al. Infectious Diseases Society of America position statement on telehealth and telemedicine as applied to the practice of infectious diseases. Clin Infect Dis. 2017;64(3):237–42.
65. Parameters JTFoP. American Academy of Allergy AtaI, American College of Allergy AtaI, Joint Council of Allergy AtaI. Drug allergy: an updated practice parameter. Ann Allergy Asthma Immunol. 2010;105(4):259–73.
66. Pichichero ME, Zagursky R. Penicillin and cephalosporin allergy. Ann Allergy Asthma Immunol. 2014;112(5):404–12.
67. Kaye KS, Pogue JM. Infections caused by resistant gram-negative bacteria: epidemiology and management. Pharmacotherapy. 2015;35(10):949–62.
68. Charneski L, Deshpande G, Smith SW. Impact of an antimicrobial allergy label in the medical record on clinical outcomes in hospitalized patients. Pharmacotherapy. 2011;31(8):742–7.
69. Macy E, Contreras R. Health care use and serious infection prevalence associated with penicillin "allergy" in hospitalized patients: a cohort study. J Allergy Clin Immunol. 2014;133(3):790–6.
70. McDanel JS, Perencevich EN, Diekema DJ, et al. Comparative effectiveness of beta-lactams versus vancomycin for treatment of methicillin-susceptible Staphylococcus aureus bloodstream infections among 122 hospitals. Clin Infect Dis. 2015;61(3):361–7.
71. Blumenthal KG, Parker RA, Shenoy ES, Walensky RP. Improving clinical outcomes in patients with methicillin-sensitive Staphylococcus aureus bacteremia and reported penicillin allergy. Clin Infect Dis. 2015;61(5):741–9.
72. Blumenthal KG, Shenoy ES, Huang M, Kuhlen JL, Ware WA, Parker RA, et al. The impact of reporting a prior penicillin allergy on the treatment of methicillin-sensitive Staphylococcus aureus bacteremia. PLoS One. 2016;11(7):e0159406.
73. Romano A, Gaeta F, Arribas Poves MF, Valluzzi RL. Cross-reactivity among beta-lactams. Curr Allergy Asthma Rep. 2016;16(3):24.
74. Pre-Pen (benzylpenicilloyl polylysine) package insert,. In. Plainville, CT: Hospira, Inc, AllerQuest LLC; 2009.
75. Macy E, Mangat R, Burchette RJ. Penicillin skin testing in advance of need: multiyear follow-up in 568 test result-negative subjects exposed to oral penicillins. J Allergy Clin Immunol. 2003;111(5):1111–5.
76. Sogn DD, Evans R, Shepherd GM, et al. Results of the National Institute of Allergy and Infectious Diseases collaborative clinical trial to test the predictive value of skin testing with major and minor penicillin derivatives in hospitalized adults. Arch Intern Med. 1992;152(5):1025–32.
77. Leis JA, Palmay L, Ho G, Raybardhan S, Gill S, Kan T, et al. Point-of-care Beta-lactam allergy skin testing by antimicrobial stewardship programs: a pragmatic multicenter prospective evaluation. Clin Infect Dis. 2017;65:1059–65.
78. Jones BM, Bland CM. Penicillin skin testing as an antimicrobial stewardship initiative. Am J Health Syst Pharm. 2017;74(4):232–7.