Importance of Antimicrobial Stewardship

Jessica Hernandez-Holzman
Hospital Epidemiology EPID 680
Submitted: 03/15/2019
This essay is submitted to meet partially Competency # 5 of the Hospital and Molecular
Epidemiology Track of Epidemiology MPH Program, University of Michigan, School of Public
Health
Background and Significance

The term ‘antimicrobial stewardship’ is a relatively recent phenomenon that has quickly
shaped our antimicrobial practices today. It wasn’t until 1996 that articles were published with
the term ‘antimicrobial stewardship’ or ‘antibiotic stewardship’ and did not start to gain much
recognition until roughly 2008 (1). Since then, the term ‘antimicrobial stewardship’ has been
adopted in various published articles, with over 2,500 articles identified in 2017 (1). As the word
‘stewardship’ can have various meanings, a recent article has tried to standardize the definition
of antimicrobial stewardship as “a coherent set of actions which promote using antimicrobials in
ways that ensure sustainable access to effective therapy for all who need them” (1). This sense
of responsibility has become important in our definition of antimicrobial stewardship today. With
a rise in antimicrobial resistance, it has become necessary to mitigate the negative effects
antibiotics can have within communities. Various studies show evidence that less than 50% of
antimicrobials used for treatment were actually necessary, showing the need for better practices
with antimicrobial use (2-4).

Concept Principles and Activities

The overarching principle of antimicrobial stewardship programs is to combat

antimicrobial resistance while properly administering antibiotics (5). To achieve this goal, there
are various activities that have been outlined in multiple studies. Some of the most common
activities, also termed interventions, are education/guidelines, formulary restrictions, review and
feedback, and antimicrobial cycling (1, 2, 6, 7). Through these activities, antimicrobial
resistance can be regulated and reduced.

In order to implement an effective antimicrobial stewardship program, emphasis should

first be placed on educating clinicians on proper antibiotic use. As clinicians are the individuals
that are responsible for prescribing antibiotics, educating them on the appropriacy of antibiotics
to be administered is the first step in achieving good antimicrobial stewardship (2, 6-8).
Formularies, or restrictions put in to place on the antibiotics that a healthcare facility has
approved to be prescribed, is arguably the most effective activity to reduce antibiotic resistance
(2, 6, 7). Some restrictions can be implemented through a review or approval program. This is
done to restrict the availability of certain antibiotics or regulate the appropriateness of antibiotic
use. Clinicians may need approval of therapeutic treatment choice prior to administration of
antibiotics to the patient. Through these restrictions, not only have studies shown a decrease in
antimicrobial resistance but they have also shown decreases in healthcare costs (2, 6). Lastly,
antimicrobial cycling is an important activity that needs to be considered when implementing an
antimicrobial stewardship program. Antimicrobial cycling has been identified as a way to reduce
the possibility of antimicrobial resistance. Through the action of dictating the timeframe an
antimicrobial can be administered, emergence of bacterial resistance can be reduced (2, 6).
Together these activities can be implemented collectively to achieve an optimal antimicrobial
stewardship program to combat not only antimicrobial resistance, but also decrease costs in the
healthcare system.
Application and Impact

A study conducted by Arco et al. showed that antimicrobial stewardship programs can
enhance the sensitivity of common antimicrobials used against virulent pathogens. They
showed imipenem had a 10% increase in sensitivity to Pseudomonas aeruginosa and a 13%
decrease in extended-spectrum beta-lactamases (ESBL) Klebsiella pneumoniae strains over
the three year study period after implementation of an antimicrobial stewardship program (9).
Although the number of cases were unchanged for methicillin-resistant Staphylococcus aureus
(MRSA), a study conducted by Frank at al. showed about a 70% reduction in MRSA cases over
a two year study period (10).

These programs are being implemented in various healthcare settings to accomplish the
goals of educating clinicians, reducing antibiotic resistance, and reducing overall healthcare
costs. As exemplified above, application of antimicrobial stewardship programs have been
proven to improve rates of hospital and community acquired pathogens. Several studies have
been conducted illustrating the benefits of antimicrobial stewardship programs through improved
rates of bacteremia, respiratory infections, intrinsically resistant organisms, and reduced
hospital costs (4, 11-13). These improvements have had an impact in improved patient
outcomes while also decreasing antimicrobial resistance. Reduced hospital costs have also
been in part due to shorter hospital stays from diminished antimicrobial resistance. Because of
this, reducing hospital costs have now become an objective being incorporated into
antimicrobial stewardship programs within healthcare systems (6).

Summary

The need for antimicrobial stewardship programs have been found to be beneficial and
necessary. Antimicrobial stewardship programs aim to optimize antibiotic choice, emphasizing
the importance of appropriateness and length of treatment to reduce antimicrobial resistance
(13). There have been found to be not only benefits in reducing the use of unnecessary
antibiotics but has also been found to decrease cost in healthcare settings (3). Significant
reductions in antimicrobial resistance have been found in 61% of cases in a study conducted by
Nathwani et al. and roughly $732.00 per patient could be saved after implementation of an
antimicrobial stewardship program (14). As beneficial as antimicrobial stewardship programs
have been in our society, more needs to be done to decrease the rate of antimicrobial
resistance to aid in preventing unnecessary infections in our communities.
References

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