|Year : 2016 | Volume
| Issue : 3 | Page : 79-82
Antibiotic stewardship program: A dilemma for control of infections
Immad Arif1, Salman Assad1, Usman Ghani1, Shuja Assad2
1 Department of Surgical Critical Care, Shifa College of Medicine, Islamabad, Pakistan
2 Department of Surgery, Nawaz Sharif Medical College, University of Gujrat, Gujrat, Pakistan
|Date of Submission||02-Aug-2016|
|Date of Acceptance||13-Sep-2016|
|Date of Web Publication||30-Sep-2016|
Department of Surgical Critical Care, Shifa College of Medicine, Islamabad
Source of Support: None, Conflict of Interest: None
Aim: To evaluate interventions which are commonly used in inpatient antibiotic stewardship program (ASP) and its effectiveness on outcomes related to changes in antimicrobial prescribing and health-related cost. Methods: We have conducted a meta-analysis based on clinical database taken from PubMed, Google Scholar, and EMBASE from 2012 to 2016. After reviewing abstracts and extracting exclusion criteria data, we found outcomes related to changes in prescribing practices and cost-related outcomes according to types of interventions used in ASP. Results: A significant change was observed after the implementation of ASP, which led to better prescribing practices in physicians and obviously decreased antibiotic consumption. A major decrease in the hospital and patient costs also favors the implementation of ASP, keeping in mind the increase resistance to antimicrobial agents and ever rising health-care cost. Conclusion: ASPs help to improve the practices of physicians with components of audit feedback, guideline implementation, and decision. Current data are sufficient to make stewardship implementation a priority in all hospitals, especially given the emerging threat of resistance and raising health-care costs.
Keywords: Antibiotics stewardship program, cost, hospitals, infections, resistance
|How to cite this article:|
Arif I, Assad S, Ghani U, Assad S. Antibiotic stewardship program: A dilemma for control of infections. Transl Surg 2016;1:79-82
| Introduction|| |
Since the antibiotics started to use in clinic during the 1930s-1940s, excessive and unjustified consumption of antibiotics and the well-recognized ability of bacteria exposed to antimicrobials agents to develop resistance against them has led to the emergence of multidrug-resistant and even pan-resistant bacteria that are resistant to all known antibiotics. Combined with the fact that over the last decade, there has been a decline in the development and approval of newer agents, our ability to treat infectious diseases is being rapidly exhausted. 
It is estimated by the Center for Disease Control and Prevention that more than 2 million people are infected with antibiotic-resistant organisms, resulting in approximately 23,000 deaths annually.  Antibiotics were used once to treat lethal infections reducing both morbidity and mortality; however, it is now estimated that around 50% of antibiotics prescribed in hospitals are inappropriate or unnecessary. , In the year 2009, more than 3 million kilogram of antibiotics were administered in the United States.  Infections which involve resistant pathogens not only increase mortality but are also associated with increased length of stay (LOS) and costs.  Recognizing the need to avert, detect, and control the emergence of antibiotic resistant pathogens, the Infectious Diseases Society of America in 1997 published "Guidelines for the Prevention of Antimicrobial Resistance in Hospitals." In the year 2007, "Guidelines for Developing an Institutional Program to Enhance Antimicrobial Stewardship" were issued to encourage the concept of antimicrobial stewardship to improve antibiotic use to improve patient care.  Antibiotic stewardships programs (ASPs) aim to prevent the emergence of antimicrobial resistance by optimizing antimicrobial therapy in patients through proper selection, dosing, and duration of use, thus reducing adverse reaction and secondary infections, which lead to decreased morbidity, mortality, LOS, and health-related cost. 
| Methods|| |
We conducted a meta-analysis based on literature review of antibiotics stewardship using PubMed, Google Scholar, and EMBASE from 2012 to May 2016. We limited the results to studies published in English language and which enrolled human cases [Figure 1]. Additional studies were identified from recent systemic review and references of relevant articles. Clinical studies were excluded based on following exclusion criteria such as identified no intervention, intervention mentioned but the effect on the intervention not assessed, demographics not given, did not report at least one outcomes of interest (prescribing or cost related), studies looking at fungal or viral infections, outpatient settings, and studies not conducted in the North America.
From the included studies, data were extracted into tables which looked at hospital demographics and settings, type of intervention used in the ASP at the hospital, outcomes in terms of action taken regarding recommendations and effect of the interventions on antibiotic prescribing and health-related costs.
| Results|| |
We reviewed 95 studies, of which only 9 clinical studies were included after being carefully screened by investigators. All literature data based on research articles on ASPs (100%) that were conducted in hospitals situated in the North America [Table 1]. Our database included studies published between 2012 and May 2016. These studies focus on all the outcomes of interest while two did not mention health-care cost-related outcomes and one did not mention changes in prescription practice observed after implementation of ASP. The setting for the studies conducted included rural hospitals, community hospitals, acute care hospitals, and tertiary care academic hospitals. Forty-four percent studies were conducted at hospitals with <500 beds, 44% had 500-1000 beds, and one study did not specify how many beds, it was, however, conducted at five tertiary care hospitals. Only one study (11%) has <500 patients in their sample size. Twenty-two percent had 500-1000 patients and 44% had more than a 100 patients. Two studies (22%) did not mention the exact number of patients included in their study.
Nine studies reported a number of recommendation made by ASP, and additional assessments were made regarding acceptance, rejection, or further evaluation of these suggestions [Table 2]. In all nine studies, high number of recommendations and interventions were made by the ASP team. One study reported a gradual increase in the number of recommendations made over the period of 3 years. The majority of recommendations were accepted in all studies and small percentage was declined or demanded further clarification. It was seen that most common recommendation made were a reduction in the use of unjustified empirical therapy and de-escalation to narrow spectrum antibiotics. A major change in prescribing patterns was seen with studies showing a reduction of antibiotic use and streamlining of the use of antibiotics [Table 2].
Apart from two studies that did not focus on health-related costs, the other six clinical studies indicated a decrease in financial spending. Outcomes were mentioned in costs related to pharmaceutical purchases, cost per patient days, average cost savings per year, and anti-infective expenditure. Costs to hospitals and patients decreased significantly after the implementation of the ASP at hospitals, even after taking into account the implementation cost of setting up and running the program.
| Discussion|| |
Interventions used in all the studies were based on a standard pattern of antimicrobial stewardship program guidelines; however, hospitals used specific parts of the program tailored to their specific requirements and ease of implementation. It was seen that postprescriptive audit with intervention was the common intervention used in all studies (100%) [Table 3]. Feedback regarding recommendations made by the teams and its implementation and results was another thing common in all programs in different studies. In most studies, a more detailed look showed physicians and pharmacist were the key members of the antimicrobial stewardship team from within the hospital, except in one study were a small community hospital employed a physician leader, who led the ASPs and made recommendations once weekly by reviewing electronic medical records prospectively. Formulary restrictions with preauthorization were seen in one large tertiary care setup (11%). One hospital used data mining software to generate patient charts from pharmacy, clinical, and microbiological data on all inpatients receiving antimicrobials and used the information to make decisions regarding antimicrobial prescribing [Table 3].
The research conducted by Nowak et al.  showed that antimicrobial expenses which had increased by an average of 14.4% annually in the years preceding ASP implementation decreased by 9.75% in the 1 st year of the program and remained relatively stable in the following years, with overall cumulative cost savings estimated at $1.7 million. The results also showed that antimicrobial consumption had risen in the years before ASP inception. After the initiation of ASP in 2007, the values generally declined. The use of almost all antibiotic classes trended downward in the years after ASP inception. Notably, average total quinolone use in the four pre-ASP years was 159.3 defined daily dose's (DDDs) per 1000 patient days; overall quinolone use fell 44% to an average of 114.9 DDDs per 1000 patient-day in the four post-ASP years. Similar trends were seen with vancomycin, carbapenem, and piperacillin-tazobactam, whereas the use of first-line antimicrobials, ceftriaxone, metronidazole, and doxycycline remained flat or increased slightly.
In the research by Storey et al.,  there was 22% reduction in the mean monthly use of all antimicrobial agents per 100 in admission compared to the baseline period. There was a 16% reduction in mean monthly antimicrobial use per 1000 patient days and a 25% reduction in cost per patient day. Severe sepsis order sets and a parenteral to oral conversion protocol were implemented during the intervention period. The order sets did not limit the duration of antimicrobial therapy and the parenteral to oral conversion protocol included only five antimicrobial agents eligible for substitution at the same dose and frequency. Nevertheless, we cannot exclude the possibility that these additional interventions may have had an impact on antimicrobial use and cost.
The research by Pate et al. showed that there was 21% reduction in mean monthly antimicrobial use per 1000 patient days and 28% reduction in mean monthly cost per patient day during the intervention period compared with baseline values. There was also statistically significant reduction in the use of levofloxacin, all quinolones, linezolid, metronidazole, all antibacterials, and antifungals. The interventions which resulted in a decrease in the use and cost of antibiotics were discontinuation of one or more agents, modification of antibiotic duration, and specific agent selection.
| Conclusion|| |
ASPs help to improve the practices of physicians with components of audit feedback, guideline implementation, and decision. This leads to decrease in unnecessary and possibly dangerous treatment. After ASP implementation, antimicrobial expenditures dropped not only for the hospitals but also for patient expenses. Future research should include more studies conducted at multicenter large health-care systems to advance knowledge further than the existing evidence base from single-site studies that have focused mainly on antimicrobial outcomes. Nevertheless, current data are sufficient to make stewardship implementation a priority in all hospitals, especially given the emerging threat of resistance and raising health-care costs.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]