The importance of antimicrobial stewardship in the fight against antimicrobial resistance (AMR)

• Antimicrobial resistance (AMR) is a major global health threat worsened by the inappropriate use of antimicrobial medicines (e.g. antibiotics)
• Antimicrobial stewardship not only helps to prevent AMR but may also enhance patient care by providing education and resources to healthcare professionals on the optimal use of antibiotics
• Healthcare leaders can spearhead system-wide efforts to promote antimicrobial stewardship by dedicating resources to support clinician and patient education, institutional treatment guidelines, audit and feedback of prescribing practices, and other recommended interventions

Antimicrobial resistance (AMR) is a global health threat that significantly burdens not just patients and caregivers, but the entire healthcare system. As part of World AMR Awareness Week, which takes place November 18-24, Healthcare Transformers takes a look at this vital issue and the role healthcare leaders can play to address it through effective antimicrobial stewardship. AMR occurs when infectious pathogens, such as bacteria, become resistant to antimicrobial medicines (e.g., antibiotics), making treatment of infections less effective or even impossible.^1,2

The growing prevalence of multidrug-resistant pathogens arises from improper, unrestricted, and/or overuse of antibiotics. It is estimated that up to 30% of hospital antibiotic prescriptions are unnecessary or suboptimal.¹ To help address AMR, healthcare organizations and regulatory agencies are advancing antimicrobial stewardship programs to promote the appropriate use of antimicrobials in order to reduce the selective pressure that drives the prevalence of AMR.

Antimicrobial stewardship involves efforts to systematically measure and improve antibiotic prescribing using evidence-based guidance.^1,2 Healthcare leaders can advocate for robust antimicrobial stewardship programs that can help clinical teams make appropriate treatment decisions regarding drug choice, dose, route, and duration, leading to better patient care  and decreasing the risk for AMR.

Within the healthcare community, there are several barriers that prevent the optimal prescription of antibiotic treatments. Some of the challenges include:²

• Fear that withholding antibiotics could lead to poor outcomes
• Lack of knowledge about antimicrobial stewardship principles and best practices
• Perceived patient expectations and concern over patient satisfaction
• Limited access to clinical diagnostics or microbiological testing
• Lack of communication
• Limited infrastructure and data access

To address the global challenge of AMR, health systems can encourage and support antimicrobial stewardship programs at the local and regional levels. The World Health Organization (WHO) has published a list of ten stewardship interventions that promote the optimal usage of antibiotics in the healthcare setting, with the goal of improving patient care and decreasing AMR:²

1. Clinician education: Ongoing training and education for physicians and healthcare staff, particularly on up-to-date prescribing practices and treatment guidelines, is critical to increasing awareness of the threat of AMR and to addressing information gaps.

2. Patient and public education: Mass educational campaigns and direct clinician/patient education are both needed to increase awareness of AMR, inform patients on the proper use of antimicrobial agents, and to counter misinformation and misconceptions.

3. Institution-specific guidelines for managing common infections: Adapting international or national standards to reflect local epidemiology and resources enables standardization in care and reduces variations in antimicrobial prescribing practices.

4. Cumulative antibiograms: Also known as cumulative antimicrobial susceptibility test data, antibiograms provide information on the susceptibility of a given pathogen and can inform the empiric treatment strategies incorporated into local guidelines.

5. Prior authorization of restricted antimicrobials: This point-of-care intervention requires stewardship team members, pharmacists, or infectious diseases physicians to provide pre-approval before clinicians can prescribe certain restricted antimicrobials. This step enforces targeted treatment options over broad-spectrum antibiotics and addresses potential drug shortages.

6. De-labeling of spurious antibiotic allergies: Clinicians should actively clarify antibiotic allergies and, in some cases, assess patients for potentially erroneous antibiotic allergy labels. Allergy de-labeling will enable patients access to more treatment options, particularly first-line antibiotics.

7. Prospective audit and feedback: Review of active antimicrobial use in individual patients and real-time recommendations can help highlight for clinical teams strategies to optimize therapy and provide “teachable moments” that reinforce stewardship principles.

8. Self-directed antibiotic reassessments (antibiotic timeouts): Reassessing the need for antibiotics routinely throughout hospitalization is required to ensure continued appropriateness and to prevent continuation of incorrect and unnecessary treatment.

9. Dose optimization: Optimizing drug doses and administration routes and re-evaluating these parameters is critical to maximizing effectiveness and minimizing toxicity of drugs, which can impact patient outcomes.

10. Duration optimization: Based on the diagnosis, microbiological data, and patient response, physicians can, for many common infections, use shorter treatment durations compared with what was previously used, avoiding unnecessary exposure to therapy.

Healthcare leaders play a vital role in setting institutional priorities and mobilizing the necessary resources that can drive robust implementation of these stewardship interventions. This will lead to the responsible usage of antimicrobial therapies within their organizations, improving the quality of patient care and preventing the rise of AMR.

All stakeholders within the health system, including all clinicians (e.g., hospitalists, critical care physicians, surgeons, infectious disease physicians, etc.), as well as hospital pharmacists, clinical microbiologists, infection control staff, and administrators must be invested in antimicrobial stewardship in order for its impact to be meaningful and sustainable.

Antimicrobial stewardship positively impacts patient outcomes and decreases hospitalization stays and re-hospitalizations, resulting in cost savings for hospitals. In 2021, there were almost 5 million deaths worldwide associated with bacterial AMR. In the US, for example, reports show that AMR hospitalizations cost $29,000 USD per patient.^3,4 By 2050, the number of patient deaths due to AMR could reach approximately 8-10 million globally each year and a total financial burden of $100 trillion USD.

Antimicrobial stewardship programs have been shown to save healthcare organizations $200,000-$900,000 USD yearly, with the potential to decrease costs per patient per day by a significant amount. A study found that such programs can reduce the rate of hospital-acquired infections caused by multidrug-resistant organisms in the intensive care unit by 65% over a five-year period.^3,5

Optimizing antimicrobial prescribing and preventing AMR will help to improve patient care, lower mortality rates, and significantly reduce healthcare costs.⁶ However, without local and global action, regions may face widespread crises in both healthcare and economic stability.

While antibiotics are proven life-saving medicines, their inappropriate usage has led to widespread AMR in healthcare settings globally. Healthcare leaders have the opportunity to become advocates for antimicrobial stewardship by establishing stewardship as an institutional priority and providing the resources necessary to implement system-wide stewardship interventions. By taking action, organizations can dramatically impact patient lives and help address this global health crisis.