How to Establish an Antibiotic Stewardship Program

What are Antibiotic Stewardship Programs? 

By definition, antibiotics generally only work against bacterial illnesses. But despite this, 47 million prescriptions annually are “completely unnecessary.” 

According to a BMJ study of 130 million ambulatory care visits to office-based healthcare providers, 57 percent of indications for antibiotic prescription were deemed appropriate and 25 percent were inappropriate. The remaining 18 percent lacked an appropriate or inappropriate indication. 

A recent Pew Research Center study also found that over half (52 percent) of COVID-19 hospitalizations during the first six months of the pandemic included antibiotic prescribing.  

The misuse of antibiotics has significantly contributed to antibiotic resistance, which the World Health Organization (WHO) considered one of the ten largest global health threats in 2019.

Antibiotic stewardship programs are implemented in various care settings, including doctors’ offices, hospitals, and long-term care facilities to ensure that antibiotics are used only when necessary and appropriate. 

These programs also ensure that patients receive the most effective treatment option, and that the treatment is administered correctly. 

Overall, antibiotic stewardship improves clinical outcomes and minimizes harm by slowing the emergence of resistant bacteria and optimizing a patient’s course of therapy. 

These initiatives will help to protect individuals’ health and help them recover as quickly as possible.

Challenges of Antimicrobial Stewardship Programs

Antibiotic stewardship programs rely on a multidisciplinary stewardship team consisting of experts in treatment, diagnosis, and prevention of infections, as well as other key stakeholders.

And although these programs are beneficial to both patients and providers, implementing a sustainable and effective program has various challenges.

Time constraints are one of the top challenges, according to a 2020 NIH study of secondary level hospitals that implemented a stewardship program. Physicians felt that stewardship measures like pre-authorization would be difficult, especially in a crowded outpatient department. 

“In an out-patient department, we have lots of patients coming in at a time. So it might take lots of time and patience from the side of the doctors to implement it,” the physicians said in the study.

Lack of inter-departmental coordination was another challenge, according to the study. When implementing measures like stewardship, a sound management culture should exist. But in the study, physicians complained that virtually nobody was held accountable. 

“Nobody is really accountable. Pharmacist does not know why he is ordering these antibiotics. The administrator does not know why pharmacist is asking for these set of medications. The doctor would want to intend all medications which they want to prescribe,” the physicians explained. 

Other challenges in the study included minimal supporting facilities, absence of a champion, poor enforcement of regulations, and utility value of antibiogram. 

Another study from Military Medicine looked at antibiotic stewardship programs in the deployed setting. Researchers found that the majority of all sites visited reported some type of antimicrobial stewardship effort or formal program in place (67 percent).

But most of these sites did not have a charter, policy, or procedural document establishing a formal program, goals, reporting, or general functions of the team. 

Key Considerations for Antibiotic Stewardship Programs

When scientists, public health bodies, and governments globally warn that antimicrobial resistance is a health crisis, top organizations in the healthcare industry have stepped up to help combat this growing issue. 

In 2014, CDC called on all hospitals in the US to implement antibiotic stewardship programs and released the Core Elements of Hospital Antibiotic Stewardship Programs (Core Elements) to help hospitals achieve this goal. 

The Core Elements outline structural and procedural components that are associated with successful stewardship programs. 

The first element for a beneficial stewardship program is clinician commitment, which shows dedication and accountability for optimizing antibiotic prescribing and patient safety.

The second element is action for policy and practice, which will help to improve antibiotic prescribing, assess whether it is working, and modify as needed.

The third element includes tracking and reporting of antibiotic prescribing. 

And the last element is education and expertise. This includes providing educational resources to clinicians and patients on antibiotic prescribing and ensuring access to needed expertise on optimizing antibiotic prescribing. 

Currently, about 64 percent of acute-care hospitals have implemented programs aligned with the CDC’s Core Elements. In order to combat challenges, such as time constraints and lack of coordination, hospitals must implement these four elements.

This will ensure a successful and sustainable stewardship program, health experts say. 

An NIH report also found seven elements for implementing a successful antibiotics stewardship in the ICU. 

These elements include boosting leadership, audit and feedback, antibiotic time out, rapid diagnostics, clinical pathways, computerized decision support, and infection control.