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The need for antimicrobial stewardship: A public health concern
Journal of Infection and Public Health (2014) 7, 174—175
LETTER TO THE EDITOR The need for antimicrobial stewardship: A public health concern To the Editor, History has demonstrated that the introduction of a new antibiotic leads to its widespread use and the subsequent development of inevitable antibiotic resistance. Over the past 70 years of antibiotic use in clinical practice, bacteria have developed resistance to each newly introduced antibiotic, one after another. The battle against antibiotic resistance has continued to this day, but alarmingly, we are not able to develop new antibiotics as fast as in previous years [1], and bacteria are increasingly becoming resistant to multiple antibiotics. Therefore, efforts should be directed to encourage more investment in anti-infective therapies and to delay the development and spread of resistance by using antibiotics wisely and by improving infection control measures. The implementation of such a program is complicated and requires a whole systems approach. To be successful, an antibiotic stewardship program should be multifaceted and should comprise policies, guidelines, surveillance, prevalence reports, education, and audit practices to optimize prescribing methods. It is widely accepted that there is a direct correlation between the use of antibiotics and the development of antibiotic resistance [2,3]. Therefore, antibiotic stewardship assumes a high priority in every healthcare system. Many countries consider antibiotic resistance to be a public health problem, and discussions are held to inform decision-making, even up to the parliamentary level. However, despite the recognized expertise that is required to prescribe antibiotics effectively, this decision process is often left to junior staff who may or may not receive instruction from their seniors. Patients with complicated or severe infections are often managed according to the advice from infectious disease physicians or specialist microbiologists; however, the majority of patients are treated for their infections by non-specialists.
In an effort to ensure effective therapy, these non-specialists opt for broad-spectrum agents and treatment durations that are longer than necessary due to the gaps in their knowledge of antibiotics use. This sub-optimal prescribing decision process has led to the widespread inappropriate use of antibiotics. Several studies have estimated that as much as 50% of hospital antibiotic prescribing is sub-optimal [4—6]. At our institute, piperacillin/tazobactam is widely prescribed and resistance in Escherichia coli and Klebsiella pneumoniae blood isolates has more than doubled over 6 years (Fig. 1). Details on how to develop an antibiotic stewardship program are beyond the scope of this letter. However, the appropriate use of antibiotics and efforts to prevent the development of antibiotic resistance should be a top priority for a hospital board. Every healthcare institution should have a local, multi-disciplinary antibiotic management group that is responsible for developing guidelines, policies, and restrictions to reduce the risk of antibiotic resistance and to advice on the appropriate antibiotic use. For all antibiotic prescribers, there should be ongoing educational and training activities on the prudent use of antibiotics, preferably during orientation programs and every 3 years thereafter. Additionally, audits on the different aspects of antibiotic use should be encouraged. Many activity materials, toolkits, pathways, and program campaigns, e.g., ‘Start Smart,—Then Focus,’ are available in the literature [7]. Infections caused by resistant organisms have a high political profile and are a top priority in healthcare agendas in the developed world; however, antimicrobial stewardship and resistance receive much less attention in less developed countries where many antibiotics are dispensed over-the-counter. It is concerning to see the emergence of resistance, especially in Gram-negative bacteria, at a time when fewer new antimicrobial agents are being approved. A bacterial population that is exposed to antibiotics will be under selective pressure either to die off or to develop
1876-0341/$ — see front matter © 2013 King Saud Bin Abdulaziz University for Health Sciences. Published by Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.jiph.2013.05.008
The need for antimicrobial stewardship: A public health concern
175
Ethical approval Not required.
References
Figure 1 Piperacillin/tazobactam resistant Escherichia coli and Klebsiella pneumoniae blood isolates from 2006 to 2012 at Qatif Central Hospital.
resistance. Mutants with reduced susceptibility to antibiotics will be selected against, thereby leading to colonization by more difficult-to-treat organisms. The appropriate use of antimicrobial agents is an essential part of patient safety. Public health authorities should ensure that stewardship measures are in place to promote the optimal and safe use of antimicrobial agents to minimize the acquisition and spread of resistance. The combination of antimicrobial stewardship and comprehensive infection control measures has been demonstrated to limit the emergence and transmission of antimicrobial-resistant bacteria.
Funding No funding sources.
Competing interests
[1] Spellberg B, Blaser M, Guidos RJ, Boucher HW, Bradley JS, Eisenstein BI, et al. Combating antimicrobial resistance: policy recommendations to save lives. Clin Infect Dis 2011;52(Suppl 5):S397—428. [2] Livermore D. The zeitgeist of resistance. J Antimicrob Chemother 2007;60(Suppl. 1):i59—61. [3] Barbosa TM, Levy SB. The impact of antibiotic use on resistance development and persistence. Drug Resist Updat 2000;3:303—11. [4] Gerding DN. The search for good antimicrobial stewardship. Jt Comm J Qual Improv 2001;27:403—4. [5] Avorn J, Solomon DH. Cultural and economic factors that (mis)shape antibiotic use: the nonpharmacologic basis of therapeutics. Ann Intern Med 2000;133:128—35. [6] Classen DC, Evans RS, Pestotnik SL, Horn SD, Menlove RL, Burke JP. The timing of prophylactic administration of antibiotics and the risk of surgical-wound infection. N Engl J Med 1992;326:281—6. [7] Department of Health’s advisory committee on Antimicrobial Resistance Healthcare Associated Infection (ARHAI). Antimicrobial Stewardship: ‘‘Start Smart — Then Focus’’; 2011.
Arif Al-Hamad ∗ Division of Clinical Microbiology, Infection Prevention and Control Section, Qatif Central Hospital, Qatif, Saudi Arabia ∗ Correspondence to: Division of Clinical Microbiology, Department of Pathology and Laboratory Medicine, Qatif Central Hospital, P.O. Box 18476, Qatif 31911, Saudi Arabia. Tel.: +966 13 8361000x1525; fax: +966 13 8360040. E-mail addresses: [email protected], [email protected]
None declared.
12 May 2013
Available online at www.sciencedirect.com
ScienceDirect
LETTER TO THE EDITOR The need for antimicrobial stewardship: A public health concern To the Editor, History has demonstrated that the introduction of a new antibiotic leads to its widespread use and the subsequent development of inevitable antibiotic resistance. Over the past 70 years of antibiotic use in clinical practice, bacteria have developed resistance to each newly introduced antibiotic, one after another. The battle against antibiotic resistance has continued to this day, but alarmingly, we are not able to develop new antibiotics as fast as in previous years [1], and bacteria are increasingly becoming resistant to multiple antibiotics. Therefore, efforts should be directed to encourage more investment in anti-infective therapies and to delay the development and spread of resistance by using antibiotics wisely and by improving infection control measures. The implementation of such a program is complicated and requires a whole systems approach. To be successful, an antibiotic stewardship program should be multifaceted and should comprise policies, guidelines, surveillance, prevalence reports, education, and audit practices to optimize prescribing methods. It is widely accepted that there is a direct correlation between the use of antibiotics and the development of antibiotic resistance [2,3]. Therefore, antibiotic stewardship assumes a high priority in every healthcare system. Many countries consider antibiotic resistance to be a public health problem, and discussions are held to inform decision-making, even up to the parliamentary level. However, despite the recognized expertise that is required to prescribe antibiotics effectively, this decision process is often left to junior staff who may or may not receive instruction from their seniors. Patients with complicated or severe infections are often managed according to the advice from infectious disease physicians or specialist microbiologists; however, the majority of patients are treated for their infections by non-specialists.
In an effort to ensure effective therapy, these non-specialists opt for broad-spectrum agents and treatment durations that are longer than necessary due to the gaps in their knowledge of antibiotics use. This sub-optimal prescribing decision process has led to the widespread inappropriate use of antibiotics. Several studies have estimated that as much as 50% of hospital antibiotic prescribing is sub-optimal [4—6]. At our institute, piperacillin/tazobactam is widely prescribed and resistance in Escherichia coli and Klebsiella pneumoniae blood isolates has more than doubled over 6 years (Fig. 1). Details on how to develop an antibiotic stewardship program are beyond the scope of this letter. However, the appropriate use of antibiotics and efforts to prevent the development of antibiotic resistance should be a top priority for a hospital board. Every healthcare institution should have a local, multi-disciplinary antibiotic management group that is responsible for developing guidelines, policies, and restrictions to reduce the risk of antibiotic resistance and to advice on the appropriate antibiotic use. For all antibiotic prescribers, there should be ongoing educational and training activities on the prudent use of antibiotics, preferably during orientation programs and every 3 years thereafter. Additionally, audits on the different aspects of antibiotic use should be encouraged. Many activity materials, toolkits, pathways, and program campaigns, e.g., ‘Start Smart,—Then Focus,’ are available in the literature [7]. Infections caused by resistant organisms have a high political profile and are a top priority in healthcare agendas in the developed world; however, antimicrobial stewardship and resistance receive much less attention in less developed countries where many antibiotics are dispensed over-the-counter. It is concerning to see the emergence of resistance, especially in Gram-negative bacteria, at a time when fewer new antimicrobial agents are being approved. A bacterial population that is exposed to antibiotics will be under selective pressure either to die off or to develop
1876-0341/$ — see front matter © 2013 King Saud Bin Abdulaziz University for Health Sciences. Published by Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.jiph.2013.05.008
The need for antimicrobial stewardship: A public health concern
175
Ethical approval Not required.
References
Figure 1 Piperacillin/tazobactam resistant Escherichia coli and Klebsiella pneumoniae blood isolates from 2006 to 2012 at Qatif Central Hospital.
resistance. Mutants with reduced susceptibility to antibiotics will be selected against, thereby leading to colonization by more difficult-to-treat organisms. The appropriate use of antimicrobial agents is an essential part of patient safety. Public health authorities should ensure that stewardship measures are in place to promote the optimal and safe use of antimicrobial agents to minimize the acquisition and spread of resistance. The combination of antimicrobial stewardship and comprehensive infection control measures has been demonstrated to limit the emergence and transmission of antimicrobial-resistant bacteria.
Funding No funding sources.
Competing interests
[1] Spellberg B, Blaser M, Guidos RJ, Boucher HW, Bradley JS, Eisenstein BI, et al. Combating antimicrobial resistance: policy recommendations to save lives. Clin Infect Dis 2011;52(Suppl 5):S397—428. [2] Livermore D. The zeitgeist of resistance. J Antimicrob Chemother 2007;60(Suppl. 1):i59—61. [3] Barbosa TM, Levy SB. The impact of antibiotic use on resistance development and persistence. Drug Resist Updat 2000;3:303—11. [4] Gerding DN. The search for good antimicrobial stewardship. Jt Comm J Qual Improv 2001;27:403—4. [5] Avorn J, Solomon DH. Cultural and economic factors that (mis)shape antibiotic use: the nonpharmacologic basis of therapeutics. Ann Intern Med 2000;133:128—35. [6] Classen DC, Evans RS, Pestotnik SL, Horn SD, Menlove RL, Burke JP. The timing of prophylactic administration of antibiotics and the risk of surgical-wound infection. N Engl J Med 1992;326:281—6. [7] Department of Health’s advisory committee on Antimicrobial Resistance Healthcare Associated Infection (ARHAI). Antimicrobial Stewardship: ‘‘Start Smart — Then Focus’’; 2011.
Arif Al-Hamad ∗ Division of Clinical Microbiology, Infection Prevention and Control Section, Qatif Central Hospital, Qatif, Saudi Arabia ∗ Correspondence to: Division of Clinical Microbiology, Department of Pathology and Laboratory Medicine, Qatif Central Hospital, P.O. Box 18476, Qatif 31911, Saudi Arabia. Tel.: +966 13 8361000x1525; fax: +966 13 8360040. E-mail addresses: [email protected], [email protected]
None declared.
12 May 2013
Available online at www.sciencedirect.com
ScienceDirect