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George and Morris Critical Care 2010, 14:205

http://ccforum.com/content/14/1/205

RE VIE W

Pro/con debate: Should antimicrobial stewardship
programs be adopted universally in the intensive
care unit?
Philip George1 and Andrew M Morris2*
Abstract
You are director of a large multi-disciplinary ICU.
You have recently read that hospital-wide antibiotic
stewardship programs have the potential to improve
the quality and safety of care, and to reduce the
emergence of multi-drug resistant organisms and
overall costs. You are considering starting one of
these programs in your ICU, but are concerned about
the associated infrastructure costs. You are debating
whether it is worth bringing the concept forward to
your hospital’s administration to consider investing
in.

while
producing
the fewest possible
side
effects
and the
lowest
risk for
subsequent
[2].
Antimicrobial
stewardship
programs
may resistance
contain
aeffective
variety
of interventions
that
are
complementary
to
infection
prevention and control programs.
Inappropriate
antimicrobial
usage
is a significant
problem,
with approximately
50%in
of
antimicrobial
usage
being
unnecessary
or suboptimal
hospital,
community
or
ambulatory
settings
[3,4].
A
recent
study
showed
that
approximately
20%
of
patients
admitted
to
the
ICU
with
C
l
o
s
t
r
i
dium
di

c
ile
-associated
diarrhoea
were
receiving
antibiotics
without any28%
obvious
evidence
of infection,
with
an accompanying
in-hospital
mortality
[5]. Asare
a
consequence
of indiscriminate
antibiotic
use, there
reported
increases
in
the
incidence
of
infections
caused
by
resistant
organisms.
A
significant
correlation
was
demonstrated
the
in per
fluoroquinolone
prescriptions
inbetween
Canadaciprofloxacin-resistant
fromincrease
0.8 to 5.5
100 persons
per
year
and
increased
Strepto
coccuofs
pneu
mon
i
a
e
from
0%
to
1.7%
[6].
Twelve
percent
patients
previously
exposed
to
piperacillin-tazobactam
were
colonized
with
strains
of
enterobacteriaceae
resistant
to this antibiotic
[7] and the with
use ofhigher
third generation
cephalosporins
is associated
rates of
vancomycin-resistant
enterococci
and
extended-spectrum
β-lactamase-producing
organisms
Antimicrobial
resistance
emerging
inisresponse
to the[8].
selective
pressure
exerted
byof
antibiotics
also a clinical
phenomenon,
outbreaks
antibiotic-resistant
Pseudomonas
aeurogiwith
nosin
a
and
A
c
i
neto
bacter
b
a
u
m
a
n
ii
c
a
lcoaceticu
s
occurring
ICUs,
where a huge antimicrobial pressure is present [911].
Although
are to
often
life-saving,
antibiotics
also
cause
seriousthey
harm
patients,
including
Clostrcan
idium

Statement for debate
Antibiotic
stewardship programs improve patient outcomes
the ICU.and cost-effectiveness in critically ill patients in

Introduction
Antibiotic
stewardship
programs
multidisciplinary
initiatives
whose
primary
aimSociety
is toare
optimize
antibiotic
usage.
The
Infectious
Disease
of America
(IDSA)
and
the
Society
for
Health
Care
Epidemiology
of America
(SHEA)
published
guidelines
for
antimicrobial
stewardship
in
2007
aimed
at
providing
information
on
how
to
establish
suchantibiotics
programs within
health
careininstitutions
[1].
Because
are used
heavily
the ICU,
stewardship
programs
appear
particularly
applicable
to
this
setting. that
Antimicrobial
stewardship
is broadly defined
as
aduration
practice
ensures the
optimal
selection,
dose
and
of
antimicrobials
and
leads
to
the
best
clinical
outcome for the treatment or prevention of infection
difficile-associated diarrhoea, antibiotic-resistant infec*Correspondence: amorris@mtsinai.on.ca
tions and invasive candidiasis [12-14]. Antibiotics also
2
Division of Infectious Diseases, Department of Medicine, Mount Sinai
result in dangerous drug interactions, life-threatening
Hospital and University Health Network, Mount Sinai Hospital, 600 University
hypersensitivity reactions, nephrotoxicity, and QT proAvenue, Suite 415, Toronto, ON M5G 1X5, Canada
Full list of author information is available at the end of the article
longation, to name a few. Inappropriate antibiotic use
also contributes to rising drug and hospitalisation costs,
nya
and the need to preserve our current antibiotic arsenal
© 2010 BioMed Central Ltd
© 2010 BioMed Central Ltd

use A of appropriate to antibiotics and 28-day mortality [34].19]. The absence ofinfectious formal stewardship training programs for diseases fellows. such systems can improve surveillance of hospital-acquired infections and adverse drug events when comparedstudy to manual surveillance methods [30. but nonetheless veryand few effective antibiotic policies have been implemented. can improve the efficiency of antibiotic stewardship Inofapatients study looking into their benefits in the management with septic shock in an emergency department. A large teaching hospital reported ofa varying 37% reduction in the number of the days of unnecessary antibiotics use by decreasing duration of treatment and by reducing new starts [25]. The costs associated with antibiotic usage are also escalating.avoids routedelays and in duration.31].000) [21. and pharmacists has recently been a challenge to the education imperative. Through prospective audit with interaction and feedback. have shown significant reductions in the use of antibiotics and greater de-escalation to narrow-spectrum antimicrobials. ultimately in a greater strain onalso the healthcare system.22]. benefits have also been noted in an ICU-based study. Education is the cornerstone of any antibiotic stewardship program. studies using algorithms to shorten thepneumonia course antimicrobial therapy in ventilator-associated led to signifi-in cantly lower antimicrobial therapy usage with reduction costs. boardcertified physicians. order sets were found to improve initial fluid resuscitation.incidence of organ failure and improved A survey of 670 US hospitals found that implementation of guideline-recommended practices control antimicrobial use and optimize theantimicrobial duration oftoempirical therapy was associated with less resistance. Improvements in cost and e ffi cien cy of existing stewardship programs. Saving antibiotics will save money. with prescriber education and implementation of guidelines andbehaviour. vancomycin-resistant fluoroquinoloneresistant E scherich[36]. and improved physician knowledge regarding treatment and pathogen prediction were also noted [27-29]. of a prospective audit with interaction and Multiple studies using healthcare decision informationsupport technology. 14:205 http://ccforum. with systemic antibiotics being the single most costly drug class over the past decade in non-federal hospitals in the United States. and can be implemented in health care facilities sizes [23. antimicrobial stewardship appears to resistance.programs where investigators used computerised anti-infective and were able to document significant reductions in the use ofofexcessive drug adverse drug events and length hospital stay anddosage. coli and ceftazidime-resistant K leb s iel l a species Given the relationship between antimicrobial use and antimicrobial resistance. In aapproval 15-month using a web-based antimicrobial system linked into third-generation national antibiotic cephalosporin guidelines. Although preauthorization is use thought be theuse. including methicillin-resistant Staphylococcus aureus. a sustained reduction prescriptions were accompanied by These increased concordance with antibiotic guidelines [32]. clinical pathways improving antimicrobial prescribing Forof example.6 fewer days of parenteral therapy and cost savings with nodemonstrated adverse effects on clinical response [23]. Preauthorisation (also known as formulary restriction) requires approval by a pharmacist or physician prior to clinical of anto antimicrobial. In addition to direct pharmacy costs. be a logical first step in the effort to control antimicrobial . the problem appears to be even worsening [16]. antimicrobial resistance. however [20].2% of the pharmacy budget of non-federal hospitals [17]. The main benefits of this strategy are the supervision of(with antibiotic by experts and substantial cost savings some use studies demonstrating cost savings upwards of US$800. such as computer-assisted designed to provide treatment recommendations. Standardized or computer-generated physician order pre-printed sets programs. most effective method of controlling antimicrobial it does not alter the duration of therapy or the decision to give or withhold antibiotics.24]. Pro: There is justification for implementing antibiotic stewardship programs in the ICU Clinicians have long been aware of the risks of antibiotic resistance associated with inappropriate antibiotic use. costs [33]. recent study evaluate hospital-wide impact of bacteraemic a standardized order set for the the management ofnumber severe sepsis has shown that a greater of patients received appropriate initial antibiotic therapy with decreased survival [35]. ia enterococci. In addition to tracking improving use and patient care (including ofantimicrobial antibiotic resistance patterns). In another study. In 2007. dose. Prospective audit with feedback initiation of therapy and maintenance of prescribers’ autonomy. antimicrobial use is reviewed after antimicrobial therapy has been initiated and recommendations are made with regard to their appropriateness in terms of selection. hospitalisation andresulting other infrastructure costs are increased. Another study a sustained decrease in parenteral antibiotics over a 7-year period following introduction feedback [26]. antimicrobial suggestions Page 2 of 6 from an infectious disease fellow and a clinical pharmacist resulted in 1. systemic antibiotics accounted for 11. and there are a variety of methods to do so.George and Morris Critical Care 2010. and super-infections without adversely affecting the antimicrobial length of stay or mortality [18.com/content/14/1/205 has assumed greater importance with the paucity of new antibiotic development [15].

but lacks scienti fic evidence to support it. and must partner with infection control measures. outbreak investigation. In asignificant recent survey of 33 US hospitals. and environmental hygiene. Antimicrobial stewardship are also 50% compared less likely toacademic be implemented in community hospitals to hospitals [44].our a significant clinical thinking dependencechange on andinabuse of antibioticstois needed.reduce Rather. or the decision to prescribe antibiotics (1 study). Because antimicrobials in the ICU.apparent using the best available methods to optimize therapy their use through antimicrobial stewardship is crucial. is right’.Thethe efficacy of of antimicrobial stewardship programs has been subject a recent Cochrane systematic examining 66 studies from 1980 to 2003 [37]. . these sophisticated computer programs is not It is also not clear whether the reported cost-effectiveness of many of these stewardship programs takes into account thethe overall cost of these interventions above and beyond pharmacyrelated costs and expenses associated with development and distribution of educational materials. with an mortality benefit with appropriate [42]. It is also important to note that neither the published guidelines the important stewardship articles identify safety as an nor endpoint. Another potentially adverse of consequence of antibiotic restriction is the emergence new documenting resistance patterns replacing theof old ones. physician might be the a because less effective antimicrobial stewardship team member of a perceived or real lack of knowledge and experience [48]. Antibiotic use inofICUs may beand the there consequence rather than the cause resistance. imipenem-resistant P. main interventions analyzed in the review were targeted to decrease studies). information the resources required to implement and widely maintainavailable. and resistance from administration werestewardship frequent barriers to establishing antimicrobial programs. Con: The evidence for effectiveness of antimicrobial stewardship is lacking Despite the publication of guidelines for States. Of the studies reported to be beneficial.39]. and length ofclinical hospital stay) were also noted mortality in to some studies. Even though the primary aim was achieved. prevalence of antibiotic-resistant bacteria) and outcomes (for example. there was no correlation between antibioticrates guideline adherence by physicians and resistance [45]. Thereview. Two years after the publication of the IDSA/SHEA antibiotic stewardship guidelines [1] only 48% of survey respondents statedin that their hospital had a program [41]. Recent observational studies (subsequent the Cochrane review) have demonstrated that reducing antimicrobial pressure correlates with improved antimicrobial susceptibility of pathogens [38. disinfection and sterilization. the(6 duration of treatment (10 studies). in microbiological outcome (for example. infection control measures or both. Theincrease interventions addressed the antibiotic regimen (61 studies). A study the introduction new guidelines that restricted cephalosporin use was primarily aimed at reducing the incidence of cephalosporin-resistant K leb s iel l a spp. the timing of first dose studies). the The relative paucity of outcome data demonstrating benefits of antimicrobialstewardship stewardship is likelytoday due to infancy: antimicrobial programs areits where infection control programsare werewidely roughlyprescribed 30 years ago [40. is aantibiotic risk that stewardship. Another in challenge to implementing antimicrobial stewardship the ICU deals with the of confiden ce intensivists haveAinjunior the clinical judgement stewardship physician. In the survey Pope and colleagues personnel shortages (55%). only 40% of selected hospitals had antibiotic restriction policiesprograms and 60% used stop orders [43].41]. Although healthcare information technology is believed to be a detailed key component of on antimicrobial stewardship programs. including surveillance.usage this occurred atsubsethe expense of increased imipenem with the quent increase of [46]. Optimization of antibiotic use was seen in 81% of the studiesSignificant aimed atimprovements improving antimicrobial utilization. restriction does not prevent theinformulary potential overuse of available broad spectrum antibiotics routine practice [47]. could lead to a substantial in patient risk. itinremains unclear as torelated whether the reported improvements resistance rates are to antimicrobial stewardship programs. Reduction the incidence of bacterial resistance is touted as the main advantage of antimicrobial stewardship programs. financial(14%) considerations (36%). with its emphasisincrease on decreased use. above will promote optimal anti-for microbial leading to thethe best clinical outcome patients. Antimicrobial stewardship programs form only one strategy for minimizing the incidence of resistance. improving the use ofofantimicrobial agents in effectiveness the United a great deal scepticism about the and acceptability of antimicrobial stewardship programs persists. aeu roginosain by incidence aboutnecessarily 69% Thus. survey conducted by Prevention’s the United States Centers for In a Disease Control and National Nosocomial Infections Surveillance Systems. Opposition from prescribing physicians was a barrier to establishing an antimicrobial stewardship program in about 27% of cases. treatment (6 studies) ortreatment both (3(57 studies). but may be by utilized because the ‘price[41]. Antimicrobial stewardship programs usinguse the of methods describedtherapy.

Toronto. Monitoring such outcomes presents an patient excellent opportunity for infection control and other quality and safety initiatives. Mount Sinai Hospital. system would entirely replaced. There are no other competing interests. Infectious Diseases Society of America. none of the studies report any significant reduction in antimicrobial side effects as a result of these interventions. Eur J Clin Microbiol Infect Dis 2005. There is little question that antimicrobial use is is growing causally related to that antimicrobial resistance. Motyl MR. Chan CY. Conclusion Hospitals areprograms increasingly implementing antimicrobial stewardship in response toinfection increasing antimicrobial resistance (despite aggressive control practices). and resistance from administration who are reluctant to assume economic risk. Dinubile MJ. Fishman NO. that embraces change is critical to implementation a successful antimicrobial stewardship program. Department of Medicine. mortality rates. Mount Sinai Hospital and University Health Network. control. Kunin CM: Guidelines for improving the use of antimicrobial agents in hospitals: A statement by the Infectious Diseases Society of America. Moffet HL. Department of Medicine. ON M5G 1X5. de Azavedo JC. In short. N Engl J Med 1999. Hooton TM. Mount Sinai Hospital and University Health Network. SHEA = Society for Healthcare Epidemiology of America. Friedland I. Being major foci of antimicrobial resistance and the largest consumers of antimicrobials in most hospitals. microbiology. McGeer A. Full implementation of antibiotic stewardship requires significant investment. Toronto. and pharmacy staff are needed for the success of an antimicrobial stewardship From our experience. Suchbeexpertise has been shown to improve antimicrobial use. Focusing on patient safety initiatives and the benefits of cost savings and cost avoidance may enable hospital administrators to look upon antibiotic stewardship favourably [20]. All ICUs should have an antimicrobial stewardship program accompanied by a system monitor clinically meaningful outcomes such to as mortality and length of stay. studies [37]. ICUs should consider other strategies toprograms improve should antimicrobial utilization. 6. Suite 415. antimicrobial stewardship programs are nothing more than programs to reduce antimicrobial use with a largely unproven effect on patient care. clinical course and outcome. McGowan JE Jr. In addition to pre-authorization and/or audit-and-feedback approaches. In the systematic review by the Cochrane Collaboration on antibiotic stewardship clinical outcomes such as mortality length programs. Canada Competing interests AMM is Director of the Antimicrobial Stewardship Program at Mount Sinai Hospital and University Health Network in Toronto. 3. Bearman GM: Hospital-acquired Clostridium difficile-associated disease in the intensive care unit setting: Epidemiology. In the 2008were survey by Pope and colleagues only 25% of respondents reported clinical outcomes. Brennan PJ. Malone DC. Maselli JH. Gerding DN: The search for good antimicrobial stewardship. Suite 18-206. Burke JP. of hospital stay reported in only 15% of and the [41]. Society for Healthcare Epidemiology of America: Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. to implementing such programs include personnel financial cutbacks. Ininfecthe absence ofcontrol such monitoring. Clin Infect Dis 2007. Carpenter CF. however. Mount Sinai Hospital. leadership and a cultureofprogram. 4. Huskins WC. or even quality indicators such as patient satisfaction. Canada 2 Division of Infectious Diseases. 44:159-177. 2. Weinstein RA. Published: 25 February 2010 References 1. should be adequately achieve intendedbut aims. Jt Comm J Qual Improv 2001. 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1186/cc8219 Cite this article as: George P. 14:205. Clin Infect Dis 2001. Acquarolo A.economic outcomes. Crema L: Role of the infectious diseases specialist consultant on the appropriateness of antimicrobial therapy prescription in an intensive care unit. Candiani A. Am J Infect Control 2008. doi:10. 49. 33:289-295. Pan A. Mondello P. 36:283-290. . Raineri E. Morris AM: Pro/con debate: Should antimicrobial stewardship programs be adopted universally in the intensive care unit? Critical Care 2010.