a. Antimicrobial Drug Stewardship

The physician’s role and responsibility for the management of antimicrobial drug resources is substantial (Arnold and Straus 2005). The goal of any clinical intervention with an antimicrobial agent is concisely expressed by Tenover as “the prudent use of the appropriate drug at the appropriate dose and for the appropriate duration” (Tenover 2006). Thus, the primary objective is the “eradication of the infection while minimizing side effects” (Paskovaty et al. 2005). 

The Canadian Medical Association’s Committee on Antibiotic Resistance suggests that antimicrobial stewardship may be the key to controlling antimicrobial resistance (Conly 2002). Similar calls to action around stewardship initiatives have been made by the CDC and WHO. Within these programs emphasis is placed on establishing the need for and the choice of antimicrobial drugs, starting with knowledge of the local pathogen prevalence involved in a particular infection (Fishman 2006). 

According to a survey of hospital practitioners, barriers to establishing an antimicrobial stewardship program include (Pope et al. 2009):

From a resource perspective, critical barriers to achieving optimal infection management include; lack of timely laboratory diagnostic information and the availability of community or regional AMDR sensitivity information. In developing nations, access to effective agents may be limited. Community, regional, and global surveillance networks are also lacking. 

The CDC Get Smart (launched in 2002) and WHO campaigns to prevent antimicrobial resistance provide evidence-based principles for judicious use of antimicrobial preparations and tools for implementation. The program emphasizes effective antimicrobial treatment of infections through:

• Use of narrow-spectrum agents
• Avoidance of excessive durations of therapy
• Restricting use of broad-spectrum or more potent antimicrobial preparations to treatment of serious infections when the pathogen is not known or when other effective agents are unavailable 

Strategies for influencing antimicrobial prescribing patterns within healthcare facilities include education; formulary restriction; prior-approval programs, including preapproved indications; automatic stop orders; academic interventions to counteract pharmaceutical influences on prescribing patterns; antimicrobial cycling; computer-assisted management programs; and active efforts to remove redundant antimicrobial combinations. In a recent follow-up report from one region of Canada, implementation of a multipronged education strategy was associated with a significant reduction in antibiotic use and associated costs (Weiss et al. 2011). 

A systematic review of controlled studies identified several successful practices. These include social marketing (eg, consumer education), practice guidelines, authorization systems, formulary restriction, and mandatory consultation, as well as peer review and feedback. It further suggested that online systems that provide clinical information, structured order entry, and decision support are promising strategies. These changes are best accomplished through an organizational, multidisciplinary, antimicrobial management program. These programs should also include the periodic feedback reviews of the effectiveness of the therapy and monitoring for possible development of AMDR (Behta et al. 2008).

Antimicrobial guidelines and treatment algorithms for infectious diseases may further aid rational use of antimicrobial preparations. When reliable data are available, local AMDR trends for infectious diseases should be considered when deciding upon inclusion of each antimicrobial (World Health Organization 2005; Liu et al. 2011).