Antibiotic stewardship: Perspective on clinical decision-making

Key Points

The increasing use of antibiotics has been a controversial issue ever since their introduction in the early 1940s.¹ Excessive and inappropriate use of these agents has led to the development of drug-resistant pathogens. In addition, a sharp decline in the development of novel antibiotics by pharmaceutical companies has also limited antimicrobial options for treatment.² As a result, not only are infections difficult to treat; they also can lead to worsening of patient outcomes and higher healthcare costs.³

For this reason, the Infectious Diseases Society of America (IDSA) and the Society for Healthcare Epidemiology of America (SHEA) developed guidelines to establish of antibiotic stewardship to maximize appropriate drug therapy, improve clinical outcomes, prevent the emergence of resistance, and reduce adverse drug events.⁴

The guidelines received collaborative support from the American Academy of Pediatrics, the Infectious Diseases Society for Obstetrics and Gynecology, the Pediatric Infectious Diseases Society, the Society for Hospital Medicine, the Society of Infectious Diseases Pharmacists, and the American Society of Health-System Pharmacists.

Antimicrobial stewardship programs (ASPs) are intended to guide practitioners in designing effective antimicrobial therapies to improve patient outcomes while avoiding any unnecessary antibiotic exposure. It is important for healthcare professionals to follow the development of these agents, identify their misuse, and integrate antibiotic stewardship into their practices.⁵

Many healthcare facilities have implemented programs that use the IDSA and SHEA guidelines to aid practitioners in appropriately streamlining therapy that specifically targets pathogens.⁴ Along with infection control, these efforts have limited the emergence and transmission of resistant pathogens and reduced healthcare costs while maintaining a high standard of care.⁴ Bantar et al showed that these initiatives can save hospitals more than $900,000 over 18 months.⁶

The ID pharmacist

Although ASPs involve multidisciplinary input, the infectious diseases (ID) pharmacist is a key player.⁷ The ID pharmacist provides prospective audits on the appropriateness of antimicrobial therapies as well as recommendations to providers and disseminates information regarding local patterns of antimicrobial resistance.⁵ The ID pharmacist also has substantial influence on hospital formulary restrictions designed to prevent misuse and overuse of antibiotics.⁷

Once trained and under the supervision of the ID specialist, clinical and staff pharmacists can assume modest strategies in ASPs by ensuring appropriate antimicrobial selection, correct dose, adequate duration of therapy, and patient compliance.⁸

Role of the pharmacist: A clinical example

A 50-year-old male with a ureteral stent presents to the hospital with signs and symptoms of a urinary tract infection (UTI). The attending physician is waiting for your antibiotic recommendation.

The patient has normal liver and renal function. On the basis of the type of infection, local sensitivity patterns, and the most likely pathogens, such as Escherichia coli, you recommend the initiation of ciprofloxacin while awaiting urine and blood cultures, susceptibilities, and urinalysis.⁹

The laboratory later reports negative blood cultures, but urine cultures are reported to be positive for Enterococcus faecalis susceptible to penicillin, and the urinalysis shows evidence of white blood cells and bacteria. As a result of these findings, you recommend switching to a 14-day course of amoxicillin/clavulanate, a penicillin indicated for treatment of complicated UTIs.^9,10 You also provide the appropriate dose and counseling for the patient.

This example illustrates the critical role pharmacists play in implementing antibiotic stewardship. Clinical pharmacists aid physicians in applying their knowledge of infectious disease to perform audits of antimicrobial therapy and reduce inappropriate use.⁴

By applying their clinical expertise and integrating a stepwise approach, pharmacists help develop therapies that specifically target causative pathogens, with the goal of improving patient outcomes and preventing resistance.