Clinicians regularly have to make complex decisions about antibiotic use, balancing the benefits of effective treatment against the risks to individual patients and public health from overuse of antibiotics. Not surprisingly, they may be confused by conflicting messages about how resistance should influence their prescribing and how their prescribing influences resistance. Furthermore, because medical professionals have already established their knowledge, attitudes, and behaviors about antibiotic use, it is difficult to change their deeply established views and practice patterns.
Significant data support the importance of antibiotic prescribing practices for patients with surgical infections, in critically ill and non-critically ill patients and in community and hospital-acquired infections. Prescribing practices may influence the outcome and cost of treatment as well as the risk of some emerging infections (such as C. difficile) and resistant pathogens in the individual patient and the broader environment.
The necessity of formalized systematic approaches to the optimization of antibiotics use in the setting of surgical units worldwide, both for prophylaxis and therapy, has become increasingly urgent.
Interventions to improve antibiotic prescribing practices for patients with surgical infections should be directed at two different levels [1]:
- Patient level – which includes clinical severity, epidemiological exposures, PK/PD factors, comorbidities, prior antibiotic exposure, prior infection, or colonization with MDROs and infection source.
- Hospital level – which includes presence of in-hospital antimicrobial stewardship programs, availability of local guidelines and updated microbiological data, infection and control control policy, educational activities, and structural resources (like computer-assisted order entry).
Components of antibiotic prescribing practices at patient level that may influence outcome and the risk of developing emerging infections and antibiotic resistant infections include:
- Adequacy of antibiotic therapy/prophylaxis,
- Time to initial antibiotic therapy/prophylaxis,
- Appropriate pharmacokinetic dosing,
- Reassessment of antibiotic therapy,
- Length of treatment, and
- Avoidance of unnecessary antibiotic therapy.
A growing body of evidence demonstrates that hospital based programs dedicated to improving antibiotic use, commonly referred to as “Antibiotic Stewardship Programs” (ASPs), can both optimize the treatment of infections and reduce adverse events associated with antibiotic use.
Despite current ASPs being advocated by infectious disease specialists and discussed by national and international policy makers, ASPs coverage remains limited to only certain hospitals as well as specific service lines within hospitals [1]. ASPs incorporate a variety of strategies to optimize antibiotic use in the hospital yet the exact set of interventions essential to ASP success remains unknown. Promotion of ASPs across clinical practice is crucial to their success to ensure standardization of antibiotic use within an institution. The preferable means of improving antimicrobial stewardship is to involve a comprehensive program that incorporates collaboration among various specialties within a healthcare institution. In this context, the direct involvement of prescribers in ASPs can be highly impactful, even if in 2013 Duane et al. [2] showed poor compliance of surgical services with ASP recommendations; this was especially true for interventions targeting selective pressure. The authors concluded that by identifying services that are less compliant, programs could target their educational efforts to improve outcomes.
Multifaceted interventions are more likely to improve antibiotic prescribing practices than simple, passive interventions. Although didactic educational programs alone are generally ineffective, education is crucial in implementing antibiotic prescribing practices among prescribers.
Effective and optimal antibiotic prescribing management is part of a decision making process that requires a fundamental understanding of the evolving relationship between appropriate antibiotic use and better outcome of patients and lower incidence of antimicrobial resistance. Since physicians are primarily responsible for the decision to use antibiotics, educating them and changing the attitudes and knowledge that underlie their prescribing behavior may be crucial for improving antibiotic prescription.
Education of all health professionals involved in antibiotic prescribing should begin at undergraduate level and be consolidated with further training throughout the postgraduate years. Hospitals are responsible for educating clinical staff about their local antimicrobial stewardship programs. Active education techniques, such as academic detailing, consensus building sessions and educational workshops, should be implemented in each hospital worldwide according to its own resources.
Efforts to improve active educational programs raising awareness of the correct use of antibiotics are strongly required. The direct involvement of the prescribers in these programs may be a way to fight the cognitive dissonance that blocks prescribers in this process.
Most studies of the implementation of guidelines and prescribing practices, including for intra-abdominal infections (IAIs), have involved multifaceted interventions.
A longitudinal study of a multifaceted program demonstrated compliance with protocols and a sustained reduction in multidrug-resistant pathogens. Popovski et al. [3] performed a before-and-after study that examined multifaceted interventions to optimize antibiotic use for IAIs. Interventions included:
- Adapting published guidelines based on local susceptibility data with stratification of infection type,
- creation of educational tools, and
- educational programs involving multidisciplinary groups
When patients with IAIs were compared before the intervention (April-November 2010) to those after implementation of the guideline (April-November 2011) in a surgical unit at a tertiary care teaching hospital, they found a significant reduction in the proportion of patients who received ciprofloxacin therapy. Also, a reduction in the DOT/1000 PD for piperacillin/tazobactam was demonstrated (from 116 to 67; OR 0.6, 95% CI 0.5-0.7).
The difficulty of altering prolonged antibiotic therapy is highlighted by a very well-structured randomized, controlled trial [4] of a short, fixed duration of antibiotic therapy for IAIs versus treatment until the resolution of fever, leukocytosis, and ileus in which both the control and treatment groups had substantial non-compliance with significant extended antibiotic therapy.
As a single intervention, implementation of locally adapted, interdisciplinary evidence based guidelines that incorporate risk stratification (severity and CA-IAIs versus HA-IAIs) and local resistance data most consistently improves components of AB prescribing for surgical infections [5].
A retrospective study [6] showed that implementation of an education-based ASP achieved a significant improvement in all antimicrobial agent prescriptions and a reduction in antimicrobial drug consumption. In a surgical unit performing mainly elective major abdominal surgery and emergency surgery, they introduced both a local protocol of surgical prophylaxis and a set of guidelines for management of intra-abdominal infections (IAIs) and control of antimicrobial agent use. Comparing the pre-intervention and post-intervention periods, the mean total monthly antimicrobial use decreased by 18.8%, from 1,074.9 defined daily doses (DDD) per 1,000 patient-days to 873.0 DDD per 1,000 patient-days after the intervention. There was a significant reduction of the use of group 2 carbapenems including imipenem/cilastatin and meropenem, and ciprofloxacin.
Only by a cohesive approach with a direct involvement of prescribing physicians the battle against the inappropriate use of antibiotics in hospitals worldwide may be won.
References
- Sartelli M, Weber DG, Ruppé E, et al. Antimicrobials: a global alliance for optimizing their rational use in intra-abdominal infections (AGORA). World J Emerg Surg. 2016 Jul 15;11:33.
- Duane TM, Zuo JX, Wolfe LG, et al. Surgeons do not listen: evaluation of compliance with antimicrobial stewardship program recommendations. Am Surg 2013;79:1269-1272.
- Popovski Z, Mercuri M, Main C, et al. Multifaceted intervention to optimize antibiotic use for intra-abdominal infections. J Antimicrob Chemother 2015;70:1226-1229.
- Sawyer RG, Claridge JA, Nathens AB, et al. Trial of short-course antimicrobial therapy for intraabdominal infection. N Engl J Med. 2015;372:1996 –2005.
- Sartelli M, Duane TM, Catena F, et al. Antimicrobial Stewardship: A Call to Action for Surgeons. Surg Infect (Larchmt). 2016 Dec;17(6):625-631.
- Sartelli M, Labricciosa FM, Scoccia L, et al. Non-Restrictive Antimicrobial Stewardship Program in a General and Emergency Surgery Unit. Surg Infect (Larchmt) 2016;17:485-490.
Global Alliance for Infections in Surgery 