Antibiotic resistance (ABR) is one of the greatest threats to public health, sustainable development and security worldwide. Its prevalence has increased alarmingly over the past decades. In 2008 the acronym “ESKAPE” pathogens which refers to Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter species was proposed to highlight those pathogens where ABR is of particular concern and to emphasize which bacteria increasingly “escape” the effects of antibiotics. These organisms are increasingly multi-drug- (MDR), extensive-drug- (XDR) and pan-drug- resistant (PDR) and this process is accelerating globally.
ABR is a natural phenomenon that occurs as bacteria evolve. However, human activities have accelerated the pace at which bacteria develop and disseminate resistance. Inappropriate use of antibiotics in humans and food-producing animals, as well as poor infection prevention and control practices, contribute to the development and spread of ABR.
Although the current magnitude of the problem and its extent in both the community and the hospital adds to the complexity of any intervention, these are still necessary as healthcare workers play a central role in preventing the emergence and spread of resistance.
In hospitals, cultural, contextual, and behavioral determinants influence clinical practice, and improving behaviour in infection prevention and antibiotics prescribing practice remains a challenge. Despite evidence supporting the effectiveness of best practice, many clinicians fail to implement them, and evidence-based processes and practices that are known to optimize antibiotic use tend to be underused in routine practice. An effective and cost-effective strategy to reduce ABR should involve a multi-faceted approach aimed at optimizing antibiotic use, strengthening surveillance and infections prevention and control, and improving patient and clinician education regarding the appropriate use of antibiotics.
Antimicrobial stewardship program (ASP) is an emerging strategy designed to optimize outcomes and reduce adverse events associated with antibiotic use. Recent evidences demonstrated that ASPs significantly reduce the incidence of infections and colonization with antibiotic-resistant bacteria and Clostridium difficile infections in hospital inpatients. Therefore, every hospital worldwide should utilize existing resources to create an effective multi-disciplinary team.
The best strategies for an ASP are not definitively established and are likely to vary based on local culture, policy and routine clinical practice despite several guidelines on the topic.
Promotion of ASPs across clinical practice is crucial to their success to ensure standardization of antibiotic use within an institution. We propose that the best means of improving antimicrobial stewardship should involve collaboration among various specialties within a healthcare institution including prescribing physicians. Successful ASPs should focus on collaboration between all healthcare professionals to shared knowledge and widespread diffusion of practice. Involvement of prescribing physicians in ASPs may rise their awareness on antimicrobial resistance.
It is essential for an ASP to have at least one member who is an infectious diseases specialist. Pharmacists with advanced training or longstanding clinical experience in infectious diseases are also key actors for the design and implementation of the stewardship program interventions. In any healthcare setting, a significant amount of energy should be spent on infection prevention and control. Infection control specialists and hospital epidemiologists should be always included in the ASPs to coordinate efforts on monitoring and preventing healthcare-associated infections. Microbiologists should actively guide the proper use of tests and the flow of laboratory results. Being involved in providing surveillance data on antimicrobial resistance, they should provide periodic reports on antimicrobial resistance data allowing the multidisciplinary team to determine the ongoing burden of antimicrobial resistance in the hospital. Moreover, timely and accurate reporting of microbiology susceptibility test results allows selection of more appropriate targeted therapy, and may help reduce broad-spectrum antimicrobial use. Surgeons with adequate knowledge in surgical infections and surgical anatomy when involved in ASPs may audit antibiotic prescriptions, provide feedback to the prescribers and integrate best practices of antimicrobial use among surgeons, and act as champions among colleagues implementing change within their own sphere of influence. Infections are the main factors contributing to mortality in intensive care units (ICU). Intensivists have a critical role in treating multidrug resistant organisms in ICUs in critically ill patients. They have a crucial role in prescribing antimicrobial agents for the most challenging patients and are at the forefront of a successful ASP. Emergency departments (EDs) represent a particularly important setting for addressing inappropriate antimicrobial prescribing practices, given the frequent use of antibiotics in this setting that sits at the interface of the community and the hospital. Therefore also ED practitioners should be involved in the ASPs. Without adequate support from hospital administration, the ASP will be inadequate or inconsistent since the programs do not generate revenue. Engagement of hospital administration has been confirmed as a key factor for both developing and sustaining an ASP. Finally, an essential participant in antimicrobial stewardship who has been often unrecognized and underutilized is the “staff nurse.” Although the role of staff nurses has not formally been recognized in guidelines for implementing and operating antimicrobial ASPs they performe numerous functions that are integral to successful antimicrobial stewardship. Nurses are antibiotic first responders, central communicators, as well as 24-hour monitors of patient status.
In our hospitals a cohesive approach in order to limit the emergence of antimicrobial resistance is mandatory. Successful ASPs should focus on collaboration between all healthcare professionals in order to gain the wider-possible acceptance, share knowledge and spread best clinical practices.
Rice LB. Federal funding for the study of antimicrobial resistance in nosocomial pathogens: no ESKAPE. J Infect Dis. 2008;197:1079–1081.
Sartelli M, Weber DG, Ruppé E, Bassetti M, Wright BJ, Ansaloni L, et al. Antimicrobials: a global alliance for optimizing their rational use in intra-abdominal infections (AGORA). World J Emerg Surg. World J Emerg Surg. 2016 Jul 15;11:33.
Sartelli M, Labricciosa FM, Barbadoro P, Pagani L, Ansaloni L, Brink AJ,et al.The Global Alliance for Infections in Surgery: defining a model for antimicrobial l stewardship-results from an international cross-sectional survey. World J Emerg Surg. 2017 Aug 1;12:34. Goff DA, Kullar R, Goldstein EJC, Gilchrist M, Nathwani D, Cheng AC, Cairns KA, Escandón-Vargas K, Villegas MV, Brink A, van den Bergh D, Mendelson M. A global call from five countries to collaborate in antibiotic stewardship: united we succeed, divided we might fail. Lancet Infect Dis. 2017 Feb;17(2):e56-e63.
Barlam TF, Cosgrove SE, Abbo LM, MacDougall C, Schuetz AN, Septimus EJ, et al. Implementing an antibiotic stewardship program: guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. Clin Infect Dis. 2016;62:e51–e77.