Antimicrobial Stewardship in Acute Care Settings

Antibiotics have been used since the 1960s and have been essential in the evolution of modern hospital care. Safe, effective, and relatively inexpensive, their use expanded markedly during the 1970s and 1980s when many “new and improved” antibiotics became available; they were convenient and had a broad range of uses. One new antibiotic, for example, often replaced two or three older ones.

As the use of antibiotics grew, so did antibiotic resistance, especially with regard to hospital-associated micro-organisms. This became increasingly worrisome to the health care sector. Coupled with budgetary pressures, antibiotic resistance prompted utilization reviews, which led to antimicrobial stewardship programs in some organizations. These programs are defined in the Accreditation Canada Required Organizational Practice (widely known as “ROP”) as:

“…an activity that includes appropriate selection, dosing, route, and duration of antimicrobial therapy. The primary focus of an antimicrobial stewardship program is to optimize the use of antimicrobials to achieve the best patient outcomes, reduce the risk of infections, reduce or stabilize levels of antibiotic resistance, and promote patient safety” (Accreditation Canada, 2013).

Most stewardship programs began in large, academic medical centres that had specialists in medical microbiology, infectious diseases, and clinical pharmacy. Programs often depended on the interests of local experts, were generally pharmacy-based, and were subject to the competitive pressures of rising expenses in all drug classes. Very little acute care antimicrobial stewardship occurred outside these centres.

In the mid-1990s, the Canadian Infectious Disease Society and Health Canada co-sponsored a two-day conference called “Controlling Antimicrobial Resistance: An Integrated Action Plan for Canadians.” Experts and policy makers came together and made numerous recommendations including the establishment of “…antibiotic stewardship and antibiotic use teams in all Canadian hospitals by incorporating them into accreditation standards.” Unfortunately, very little happened after that for a number of years.

Then, in 2005, a seminal report was published by Dr. Jacques Pépin, describing a large increase in the incidence and severity of Clostridium difficile (C. difficile) in Quebec. The report claimed that C.difficile was responsible for an estimated 2,000 deaths, a claim that quickly put hospital infections in the public and political spotlight. C. difficile and Severe Acute Respiratory Syndrome (SARS) had exposed serious shortcomings in infection prevention and control(IPC) in hospitals, and the response was swift. Investments in IPC were made across Canada—infrastructure was improved, more IPC personnel were hired, and some decreases in the rates of hospital-acquired infections were noted. Antibiotic stewardship was recognized as an appropriate response to C. difficile but there were few changes outside Quebec.

The quality and safety movement

The Canadian Patient Safety Institute was established in 2003 as a federal response to the increasing focus on patient safety. Since that time, there has been a slow and steady increase in provincial and acute care infrastructure to promote safety practices. Most jurisdictions have established health quality councils or undertaken a similar initiative within government. It is vital that central structures (e.g., health authorities, provincial governments) and experts actively support the administrative functions, such as policy and priority setting, of antimicrobial stewardship programs.

Many new and robust IPC programs were created under quality and safety portfolios and their creation helped move quality and safety agendas forward. Accreditation Canada, for example, as an independent, third-party organization, markedly increased the IPC requirements in its standards to support quality improvement.

Human resources

Who then is integral to these antimicrobial stewardship portfolios? Clinical pharmacists are the backbone of acute care infrastructure. Much of the day-to-day delivery of antimicrobial stewardship programs is performed by clinical pharmacists with guidance from senior clinical pharmacists and physicians. Clinical pharmacy programs are generally well established in academic health science centres and less so in smaller health care centres because antimicrobial stewardship often has to compete against other clinical pharmacy services for resources. Quantifying a need and establishing stable funding for clinical pharmacists is an essential step in establishing antimicrobial stewardship programs.

Physicians are integral to antimicrobial stewardship programs. A local champion with specific medical knowledge can help develop and maintain these programs. Yet, most infection specialists (infectious disease specialists, medical microbiologists) work in large centres; it will be important to find ways to interest local clinicians in working on programs at smaller centres.

It will also be necessary to reconsider medical human resources as they relate to consultation and expert guidance in case management. The use of remote technology for consultation will facilitate the expansion of antimicrobial stewardship programs into more remote communities. Because of the concentration of medical expertise in large, urban centres, and the size of Canada, it will be important to develop region-specific solutions that will likely involve remote technology to support human resources.

Information technology and data collection

Two types of information are essential to antimicrobial stewardship—antimicrobial use and antimicrobial susceptibility (i.e., laboratory testing of the effectiveness of an antimicrobial agent). Most Canadian institutions do not have well-developed systems to meet these data needs. Some of this is happening as facilities are modernized and upgraded, but it is essential that the needs of antimicrobial stewardship programs be considered during laboratory or pharmacy technology upgrading efforts.

The development of provincial data collation and interpretation centres could also play a role in supporting standardized measurement of success and areas that need improvement.

Quality and safety—the connection with IPC

Administrative support for antimicrobial stewardship falls naturally within the quality and safety portfolios, and these are clearly aligned with IPC. Synergy among IPC programs can be realized quickly, as many physician champions are involved in both IPC and antimicrobial stewardship. Of course, the microbiology laboratory is also an essential partner.

Some international programs have been moving toward infection management teams, with more integration of infection prevention, diagnosis, and therapy. This may be the next logical step in Canada.

A Scottish model

The Scottish Antimicrobial Prescribing Group (see SAPG) was created to facilitate implementation of a 2008 action plan on antimicrobial resistance. Numerous lessons can be learned from its success. See http://www.aricjournal.com/content/1/1/7.

One of the primary lessons is that dedicated funding is essential—new money was identified to create the SAPG infrastructure and to fund clinical pharmacists in all of the regional boards. The same type of investment is required in Canada.

Conclusion

In the past decade, quality and safety portfolios have become increasingly important in Canadian health care organizations, better positioning Canada to tackle the difficult challenge of managing antibiotic resistance using antimicrobial stewardship programs. With serious attention and investment, antimicrobial resistance is manageable.

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