Components of Antimicrobial Stewardship Programmes

COMPONENTS OF ANTIMICROBIAL STEWARDSHIP PROGRAMMES

There are no nationally or internationally accepted guidelines on the structure of a stewardship programme, so they vary from country to country and even from one hospital to another within a geographical region. Indeed, even the titles vary, so terms like ‘good antimicrobial practice programmes’, ‘antibiotic management programmes’ and ‘antibiotic control programmes’ have all been used. There is, however, a measure of agreement on the personnel comprising an antimicrobial stewardship team. They are multidisciplinary and usually consist of:

• An infectious diseases physician

• An clinical pharmacist with infectious diseases training

• A medical microbiologist

• An infection control professional

• A hospital epidemiologist

• An information technology specialist.

In the USA the IDSA and the Society for Heathcare Epidemiology of America (SHEA) set forth stewardship guidelines in 2007 that have been widely adopted both in the USA and elsewhere; but in Europe the situation is less uniform. Here, an expert group reported in 2000 that little was known about which stewardship measures were employed in Europe and which were optimal. As a consequence, the European Commission Concerted Action Antibiotic Resistance Prevention and Control (ARPAC) survey of stewardship practices in 263 hospitals through 32 European countries was undertaken, and it reported in 2009.Table 15.1 lists both the components of the USguidelines and the six key indicators of stewardship that were the subject of the ARPAC survey.

Before considering in more detail the elements of a stewardship programme, it is worth explaining the meaning of some of the terms used in Table 15.1. In this context a prospective audit means a review of the future delivery of healthcare to ensure that best practice is being carried out, so a prospective audit with intervention and feedback is a process in which the use of antibiotics is monitored and suggestions made for improvement, where necessary, while the course of treatment is still in progress. The feedback element is the provision of information to the prescriber about the drug in question, e.g. local resistance patterns and dose information based upon pharmacokinetic data.

Most hospitals have a drugs and therapeutics committee (DTC; sometimes also known as a pharmacy and therapeutics committee) whose function is to evaluate drugs for inclusion in a hospital formulary on the basis of their efficacy, toxicity and cost. The intention is to avoid the unnecessary stocking of multiple drugs from the same class which have similar or identical properties; few hospitals stock every available aminoglycoside or third generation cephalosporin, for example. An antibiotics committee would be a subgroup of the DTC with responsibility for selecting the drugs for inclusion in the antibiotics formulary. The strategy of formulary restriction and preauthorization could limit the availability of certain antibiotics simply by excluding them from the formulary (although they could usually be obtained in exceptional circumstances if required). The preauthorization element would simply be a requirement to seek the recommendation (or even written approval) of senior clinical staff when prescribing antibiotics in a restricted category—usually those drugs whose effectiveness needs to be preserved because of their value in treating infections for which few drugs are effective, e.g. linezolid or daptomycin, or antibiotics which may predispose to other problems, e.g. clindamycin because of its link to Clostridium difficile outbreaks.

The ARPAC stewardship indicator that the hospital should have a strategic management goal of improving prescribing has important implications for the provision of resources and granting the authority to implement decisions. Establishing a stewardship programme costs money: staff time must be available for (1) the preparation of the antibiotics policy document and formulary, (2) intervention and feedback, and (3) monitoring of antibiotic use and resistance patterns. It is easier to gain approval for the necessary budget allocation if there is a publically stated management goal of improving prescribing. Where pre-authorization for selected antibiotics is a part of the programme, the greater the authority bestowed on the person(s) making the recommendations, the greater the effectiveness of the policy has been shown to be.