Question 2

College answer

Not available.

Discussion

Principles and practical aspects:

Antibiotic stewardship is a systematic approach to the responsible management of antibiotic prescribing, consisting of coordinated interventions intended to preserve the efficacy of available antibiotics. The main elements are:

• Leadership support (adequate resources for the program)
• Accountability (a physician leader taking responsibility for the program)
• Pharmacy expertise (multidisciplinary involvement of pharmacy)
• Action (implementation of auditable interventions, such as prospective approval of antibiotic prescriptions)
• Tracking (monitoring prescribing and resistance patterns)
• Reporting (feedback to prescribers)
• Education (of clinicians, about appropriate antibiotic use)

Advantages:

• Benefits would be maximal in the ICU:
  • Antibiotic use and infectious disease is prevalent in the ICU
  • Critically ill patients are the most vulnerable to adverse drug effects and resistant organisms
• Safety improvement:
  • Reduced antibiotic toxicity
  • Reduced MRO colonisation
• Reduced health care costs
  • Reduced use of expensive novel agents
  • Reduced length of ICU stay due to less MRO-induced infections
• Increased patient exposure to infections disease specialist attention
• Involvement of specialist pharmacists could improve the identification of adverse reactions and possible drug interactions, preventing morbidity
• Use of computer-assisted decision support for antibiotic prescribing could simplify prescribing
• Standardised order sets could improve empirical coverage, reducing missed infectious agents

Disadvantages:

• There is the possibility that antibiotic stewardship, with its emphasis on stopping or not starting antibiotics, could lead to patient harm from missed sepsis
• Delay imposed by the need to seek approval could lead to worse patient outcomes (as the timing of early antibiotics is thought to be important for reducing mortality)
• Manpower-expensive: increased referrals increase the workload of ID specialists
• Resource-expensive: pharmacists, physicians, administrators need to be recruited
• Resistance will emerge to the classes of drugs favoured by the stewards
• Antibiotic resistance will still develop in the community because of non-medical (eg. agricultural and veterinarian) antibiotic use
• Antibiotic stewardship may be unacceptable culturally in the closed model of ICU care
• May not improve clinical outcomes (eg. mortality) at the institution level
• No evidence that it decreases the incidence of adverse drug reactions.