Antibiotic Stewardship

The discovery of antibiotics was one of the most important medical advances of the 20th century. Their use continues to be critically important in the care of both children and adults with serious infections. However, increasing antibiotic use has also led to the development of antibiotic resistance and a rise in harms related to antibiotics, including antibiotic-associated adverse events and Clostridioides difficile infections. There is growing recognition of the broader impact of antibiotic overuse in children, including associations with obesity, asthma, and environmental allergies. Studies have demonstrated that antibiotic use is highly variable and that at least half of antibiotic prescriptions are unnecessary, highlighting that there is room for improvement.

The overarching goal of antibiotic stewardship programs (ASPs) is to collaborate with clinicians to optimize the use of antibiotics to effectively treat infections while minimizing patient harm. ASPs are most successful when they are led jointly by a physician and a pharmacist, particularly when both have infectious diseases training. There are 2 primary approaches that ASPs use in hospitals to facilitate appropriate antibiotic use among frontline clinicians: preauthorization and postprescription review. In preauthorization, clinicians request approval from the ASP before prescribing certain antibiotics. This approach enables the ASP to provide guidance early, which may improve empirical therapy for serious conditions such as sepsis and reduce unnecessary antibiotic use before it is initiated. It also enables the stewardship team to provide guidance on optimal diagnostic testing. In postprescription review, the stewardship team advises the primary team after antibiotics have been started, once additional clinical and diagnostic data are available. Postprescription review is most effective when it involves direct face-to-face interactions because this enhances communication and optimizes opportunities for education. However, postprescription review generally does not affect the first 2 to 3 days of antibiotic therapy, which often constitute a large portion of antibiotic use. Realistically, most ASPs have a hybrid approach with a combination of preauthorization and postprescription review to maximize the opportunities to impact patient care.

In addition to providing oversight of day-to-day antibiotic use and recommendations to optimize therapeutic decisions, ASPs collaborate with partners throughout the health-care system to advocate for best practices in antibiotic use. They work closely with pharmacists and the Pharmacy and Therapeutics Committee in hospitals to identify the most clinically important antibiotics to include in the institutional formulary and to develop contingency plans for antibiotic shortages. ASPs collaborate with their microbiology laboratories to develop local antibiograms to understand patterns of resistance that inform treatment recommendations. Inpatient antibiograms can assist with selecting antibiotics for infections such as pyelonephritis (eg, Does trimethoprim-sulfamethoxazole provide sufficient empirical coverage for Escherichia coli?). Outpatient antibiograms can help with selecting antibiotics for common ambulatory infections such as cellulitis (eg, Does clindamycin provide sufficient coverage for local Staphylococcus aureus isolates?). ASPs also work with microbiology laboratories to determine which diagnostic tests are most clinically useful and how they can be implemented. They coordinate with infection prevention specialists to understand trends in antibiotic resistance and C difficile infections to identify new targets for optimizing antibiotic use. ASPs assist surgeons and anesthesiologists in the creation of evidence-based perioperative antibiotic prophylaxis guidelines. They work with vascular access teams to ensure that only patients who cannot be successfully treated with oral antibiotics receive peripherally inserted central catheters.

ASPs help with antibiotic decision making in the outpatient setting as well as assisting with antibiotic use in hospitals. Most antibiotics are used in the ambulatory setting, where optimal antibiotic prescribing can be particularly challenging for many reasons: clinicians have limited time to discuss safe prescribing with patients and families, there may be a real or perceived patient expectation for antibiotics, and access to diagnostic tests to differentiate bacterial and viral illnesses can be limited. Many ASPs work closely with outpatient clinicians to develop tools that are tailored to their specific practices and challenges, including educational materials for providers and families, decision support tools that can be embedded in electronic health systems, and peer comparisons to allow providers, who may feel isolated in their daily practice, to benchmark their antibiotic prescribing habits. Most ASPs are based in hospitals, but many now dedicate both support and personnel to outpatient efforts and are increasingly extending into the community through work with hospital-affiliated community practices. As in the inpatient setting, outpatient stewardship interventions are most successful when they are driven by frontline providers, who should feel empowered to reach out to their institutional ASPs with suggestions for local initiatives to improve antibiotic use based on their firsthand experience.

Education is the cornerstone of a successful ASP. It is a critical tool to facilitate thoughtful and deliberate antibiotic prescribing and behavior change beyond individual interventions. The 4 moments of antibiotic decision making is a framework that can optimize antibiotic use by encouraging providers to reflect on their prescribing at key moments in the treatment of an infection. Moment 1 is diagnosis; it asks clinicians to pause before prescribing antibiotics to consider whether a patient’s symptoms are attributable to an infection that requires antibiotic treatment rather than a viral or noninfectious etiology that may make antibiotic therapy unnecessary. Moment 2 occurs after the decision to prescribe antibiotics is made and consists of 2 questions. One reminds clinicians to verify that they have obtained appropriate cultures before administering antibiotics and the second prompts them to determine the best empirical antibiotic therapy for the suspected infection, taking into consideration several key factors, including the likely source of infection, the severity of illness, and the patient’s history of infections and previous antibiotic susceptibility data. Moment 3 occurs 1 or more days after the initiation of antibiotic therapy and encourages prescribers to consider 3 questions: Can antibiotics be stopped? Narrowed? Or changed from intravenous to oral therapy? Clinicians should review the 3 components of moment 3 each day that a patient is receiving antibiotics, as the patient’s clinical status changes and additional diagnostic results become available. Finally, moment 4 focuses on the optimal duration of antibiotic therapy. This should be selected as soon as the infectious process is identified and should be clearly documented in the patient’s medical record. There is a growing body of evidence that shorter durations of therapy than clinicians historically prescribed are effective for common infections, for example, 5 days for community-acquired pneumonia, 7 days for ventilator-associated pneumonia, and 7 days for pyelonephritis. The shortest effective duration for the identified infectious process should be used to optimize outcomes and reduce antibiotic-associated harm.

The 4 moments can also be applied to ambulatory settings. It can be more challenging to longitudinally consider these questions throughout a treatment course in the outpatient setting, so providers should consider all 4 questions at the start of therapy. Outpatient providers should consider, at the time of prescribing, whether the patient has an infection that requires antibiotics (moment 1); which diagnostic tests are needed (moment 2); if antibiotics are indicated, what is the narrowest, safest, and shortest regimen that can be prescribed (moment 3); and whether the patient understands the expected course and follow-up plan (moment 4). ASPs and frontline clinicians should work together to find effective approaches to incorporate the 4 moments into daily practice.

ASPs can further support frontline prescribers by developing facility-specific guidelines for both the inpatient and outpatient settings. Ideally, these should be structured using a framework such as the 4 moments and should reflect local antibiotic susceptibilities, drug formulary, and patient characteristics. Frontline clinicians should inform their ASPs of the guidelines that they would find most helpful. Guidelines are most successful when developed by the ASP and then discussed with a diverse multidisciplinary group for critical feedback and to reach consensus, particularly where gaps in the data exist. For example, a urinary tract infection guideline might involve the input of primary care practitioners, hospitalists, emergency medicine specialists, intensivists, nurses, and pharmacists. When possible, these meetings should occur in person. After an iterative process, the final guidelines should be shared with relevant clinician groups, pharmacists, and nurses to promote awareness and uptake of the guidance. Input from frontline clinicians is critical to determine the most convenient format to ensure that the guideline is available at the point of care for providers across health-care settings (eg, printed handbook, institutional website, mobile application).

Increasing recognition of antibiotic resistance and other antibiotic-associated harms has led to national prioritization of antibiotic stewardship. ASPs work with partners throughout the health-care system to provide support and education around antibiotic prescribing with the goal of effectively treating infections while minimizing antibiotic-associated harms. Stewards have valuable expertise in antibiotic use and prioritize sharing that knowledge to support prescribers; do not hesitate to reach out to your local ASP with antibiotic questions.

COMMENTS:

As a general pediatrician who has practiced in both the inpatient and outpatient settings, I have found the establishment of ASPs incredibly important. Although the linkage with an ASP is easier to establish in inpatient settings, this same relationship is also critical for those who practice in the outpatient setting. As pediatricians we continue to negotiate with parents and patients when antibiotics are not needed, and the ASP and resultant guidelines can be critically important to provide the scientific basis for our decision making. I really appreciated the 4 moments of antibiotic decision making. Although all moments are important, moment 3 helped me reflect on the importance of follow-up with patients for whom antibiotics were prescribed. Having a check-in with patients and determining their history, change in symptoms, and available culture results can help determine whether the antibiotic can be stopped or the therapy narrowed. This can be an idea for important quality improvement projects for outpatient physicians.