Running Head: Antibiotic Stewardship 1

Antibiotic Stewardship

Mirela Ibrahimovic

Hospital Epidemiology: EPID 680

March 15th 2019

"This assay 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".
Running Head: Antibiotic Stewardship 2

Background and Significance

The invention of antibiotics has saved a plethora of lives and has proven to be an
impressive medical advancement. Diseases which were once lethal have become easily
treatable with the advent of antibiotics. An important consideration in regards to antibiotic
prescription is that antibiotics are not ubiquitous. Specific antibiotics are more efficient at killing
certain bacteria than others. For example, anti-staph penicillins including methicillin, nafcillin, or
dicloxacillin, have a spectrum of activity which includes streptococcus, enterococcus, and
staphylococcus. Keeping this in mind, inappropriate antibiotic prescription is foreseeable. In
recent years, multiple misuses of antibiotics have ravaged the way we practice medicine. There
are an abundance of physicians who overprescribe or inappropriately prescribe antibiotics. This
as well as patient misuse has caused antibiotic resistance to emerge as an immensely harmful
effect of antibiotic use. The erroneous use of antibiotics has placed the population at risk for
increased infections with once treatable diseases as the bacteria has adapted to evade
antibiotic mechanisms. These resistant bacteria may then spread and invade additional hosts.
Augmenting the way in which we use antibiotics and antimicrobials is a vital public health issue.
Thus, the emergence of antibiotic stewardship has been an important facet of public health. This
refers to the appointment of coordinated procedures which are implemented in patient care in
order to improve the use of antibiotics which in turn advances patient healthcare outcomes,
reduces the emergence of antibiotic resistance, and improves cost effectiveness. Antibiotic
stewardship aims to decrease the problems associated with antibiotic resistance including
therapeutic failures which may lead to an increased mortality and increased healthcare costs.
Concept and Principles and Activities of Antibiotic Stewardship
The CDC lists a summary of core elements of hospital antibiotic stewardship programs.
The list includes leadership commitment, accountability, drug expertise, action, tracking,
reporting, and education. In order to employ antibiotic stewardship it is essential to appoint the
appropriate resources to combat antibiotic resistance in terms of leadership commitment. This
includes detailed job descriptions that outline stewardship related responsibilities, establishing
appropriate timelines for staff to complete stewardship related duties, training, and providing
reassurance of participation from hospital staff. The CDC recommends assignment of a leader
to be in charge of the pharmacy and a separate leader in charge of the programs in order to
improve use of antibiotics. Action involves the execution of recommended proposals for
antibiotic stewardship. Tracking includes observation of patterns for antibiotic resistance and
prescription patterns for antibiotics. Reporting and education are comprised of informing the
healthcare staff of antibiotic use and resistance information as well as teaching healthcare
workers about appropriate prescription and antibiotic resistance, respectively. Daily stewardship
activities can be placed into two categories : passive and active. Establishing guidelines,
pathways, protocols, formulary restriction, microbiology reporting, and drug-specific criteria as
well as divulging information via CPOE and other media falls into the category of passive. Active
activities involve engaged activities which include assisting with enhancement of quality
initiatives, prospective review of antimicrobials, culture results, disease states and
recommendations to prescribers. The CDC has a list of activities to implement antibiotic
stewardship at the state and local health department level. This list relates to the core elements
mentioned earlier and includes recommendations to establish leadership, conduct surveillance,
Running Head: Antibiotic Stewardship 3

coordinate stewardship activities, develop education and tools, develop communication plans,
and informing the legislative process.

Examples of Application and Impact of Antibiotic Stewardship

An example of an application of antibiotic stewardship is the Antibiotic Management
Service at Columbia University Medical Center. They created a program called The Outpatient
Parenteral Antibiotic Therapy (OPAT). This program is in charge of coordinating care for patients
who were discharged from inpatient care and were previously on intravenous antibiotics. This
program aids in transitioning patients to outpatient care. They created a partnership with
infusion pharmacies which has granted them enhancements in regards to communication of
critical information. Another example is the Infectious Diseases Management Program at UCSF.
This is a program that is interprofessional with aims to improve antimicrobial use and care of
infectious patients. On their webpage, they list new updates to program guidelines. One
example is on December 11th 2016, they updated their UCSFMC and UCSFBCH Guidelines for
Treatment of Influenza. The capability of antibiotic stewardship is large as these programs have
a potential to decrease antibiotic resistant outbreaks and improve infectious patient care as well
as decreasing costs. A study of stewardship at a medical center which performed a
retrospective analysis of antimicrobial utilization, bacterial susceptibilities, and antibiotic costs
found that there were significant changes in Pseudomonas aeruginosa susceptibility to
tobramycin and piperacillin-tazobactam. There was also an increase in susceptibility of
Staphylococcus aureus to methicillin. The study also noted increases in cost saving as well as a
decrease in MRSA rates. Another example of impact, is a reduction in incidence of certain
antibiotic resistant gram positive infections. This was due to implementing a quarterly rotating
empiric antibiotic schedule in the ICU in Charlottsville, Virginia.
Summary
Antibiotic resistance has become a major issue for the public health. It leads to
increased costs of healthcare, increased risk of mortality, and increased transmission of certain
infections. Resistance has emerged secondary to an abundance of reasons including, but not
limited to, physician over prescription and patient misuse. With the development of antibiotic
stewardship, there are expectations for improvements for the use of antibiotics which would in
turn improve patient healthcare outcomes, improve cost saving, and decrease the prevalence of
antibiotic resistant infections. Through leadership commitment, accountability, drug expertise,
action, tracking, reporting, and education, antibiotic stewardship has made an impact on public
health. It has been shown to have an impact on reducing healthcare cost and improving
susceptibility of certain bacteria to antibiotics in addition to improving education for healthcare
workers. With all this evidence, it is easy to conclude the priority and necessity of antibiotic
stewardship.
Running Head: Antibiotic Stewardship 4

References

1. Core Elements of Hospital Antibiotic Stewardship Programs | Antibiotic Use | CDC. (n.d.).

Retrieved from

https://www.cdc.gov/antibiotic-use/healthcare/implementation/core-elements.html

2. Antibiotic resistance. (2018, February 5). Retrieved from https://www.who.int/news-

room/fInfectious

Diseases Management Program at UCSF. (n.d.). Retrieved from

https://idmp.ucsf.edu/act-

sheets/detail/antibiotic-resistance

3.Antimicrobial Stewardship. (n.d.). Retrieved from https://www.shea-

online.org/index.php/practice-

resources/priority-topics/antimicrobial-stewardship

4.NATHWANI, D. (n.d.). Antimicrobial Stewardship From Principles to Practice. BSAC.

5.Antibiotic Stewardship Implementation Framework for Health Departments | Community |

Antibiotic

Use | CDC. (n.d.). Retrieved from https://www.cdc.gov/antibiotic-

use/community/programs-
Running Head: Antibiotic Stewardship 5

measurement/state-local-activities/framework.html

6.Antibiotic Management Service. (2018, May 24). Retrieved from

https://www.infectiousdiseases.cumc.columbia.edu/antibiotic-management-service

7. Infectious Diseases Management Program at UCSF. (n.d.). Retrieved from

https://idmp.ucsf.edu/

8. Nagel, Jerod (2019). Antibiotic Overview, 5

9. Washer, L., Laraine (2019). Antimicrobial Resistance, 4-6

10. Llor, C., & Bjerrum, L. (2014). Antimicrobial resistance: Risk associated with antibiotic

overuse and

initiatives to reduce the problem. Therapeutic Advances in Drug Safety,5(6), 229-241.

doi:10.1177/2042098614554919

11. Timbrook, T. T., Hurst, J. M., & Bosso, J. A. (2016). Impact of an Antimicrobial Stewardship

Program

on Antimicrobial Utilization, Bacterial Susceptibilities, and Financial Expenditures at an

Academic

Medical Center. Hospital Pharmacy,51(9), 703-711. doi:10.1310/hpj5109-703

12. Impact of Antimicrobial Stewardship Program Interventions on Antimicrobial Resistance |

Antibiotic

Use | CDC. (n.d.). Retrieved from https://www.cdc.gov/antibiotic-

use/healthcare/evidence/asp-

int-am-resistance.html
Running Head: Antibiotic Stewardship 6
Running Head: Antibiotic Stewardship 7