Antibiotic stewardship is the responsible use of a critical and threatened health resource, namely the antimicrobial agents we depend on to prevent and treat infectious disease. Stewardship implies not only appropriate clinical decision-making for individual patients, but a population perspective that maximizes overall benefits, minimizes adverse events and costs, and, importantly, delays the onset of widespread microbial resistance to commonly used antibiotics.
Antibiotic stewardship is urgently needed because of rising rates of antimicrobial resistance, a limited manufacturing pipeline of new agents, and the morbidity burden and large costs associated with disease that is improperly treated. The misuse of antibiotics is an international problem. Infections with multi-drug resistant organisms kill about 25,000 people a year in Europe and around 19,000 in the United States. S African figures are not known but we do have the distinction of being a world leader in prevalence of gram-negative organisms with resistance (ESBL) to beta-lactam antibiotics.
Firstly, the Best Care…Always! campaign aims to raise awareness of antibiotic prescribing issues – highlighting both misuse, and appropriate use. Secondly it aims to test and implement a small set of defined interventions that measurably and positively impact the situation. Foremost among those interventions are ICU prescribing rounds, the development of tools that both document and assist prescribing decisions, including guidelines, and the development of a team approach that supports the prescriber.
Although the biggest infectious disease threats to our population, these epidemics are not currently the focus of the campaign or the antibiotic stewardship intervention. Clearly however, principles of good antimicrobial prescribing apply as much to TB and HIV/AIDS as to any other infectious disease.
This component of the campaign differs from the infection prevention interventions in that what works is not fully established. In that sense, this is both a research and an improvement initiative. Once we have learned what works, it can be spread to other sites.
No. The scientific evidence suggests that limiting choice to only a few antibiotics may be counterproductive and that diversity is important. On the other hand, many local and international experts believe it is time to change the rules of the game – “it may well be time now to challenge the right of doctors to prescribe whichever antibiotic they wish, including the dosage and duration” (G Richards, A Brink) and to guide clinicians towards optimal, evidence-based practice.
Antibiotic Prescribing Chart
It may be helpful to separate antimicrobial prescribing from the ordering of other pharmaceuticals. A separate order form for in-hospital use could contain suggestions or guidelines as well as serve as a data collection instrument.
The data we would be interested in includes:
Indication for the drug (therapy or prophylaxis)
Source of infection
Condition that is being treated
It could also contain key information that would affect drug selection, dose and duration, such as allergies, kidney or liver impairment, and could contain visual flags for extended duration of therapy.
Antibiotic Prescribing Tool download
The BCA Antibiotic Stewardship Getting Started Kit
Change concepts, measurement and principles from three SA private hospital groups.
BCA Antibiotic Stewardship Measures
Empiric therapy without confirmation
Antibiotics without appropriate cultures
“Double coverage” i.e. concurrent antibiotics in any of these three groups:
Gram-negative cover (GNB)
Gram-positive cover (GPC)
≥4 agents concurrently
Excessive duration of treatment
- These are guidelines, based on South African susceptibility data, and this list is not exhaustive.
- Occasional exceptions to the guidelines are to be expected but should be clinically justified.
- These are not funding guidelines.
3rd and 4th generation Cephalosporins
Ceftriaxone may be appropriate prophylaxis for open reduction of a closed fracture
Extended spectrum penicillins
Pip-tazo is appropriate in theatre for bowel perforation cases but this does not constitute prophylaxis, as these patients will be treated for several days
Carbapenems are appropriate in theatre for bowel perforation cases but this does not constitute prophylaxis, as these patients will be treated for several days
Vancomycin is inappropriate with the exception of penicillin-allergic patients where you do not want to use clindamycin or failure of previous surgery involving prosthetic material due to MRSA sepsis
- Dr Marthinus Senekal, Pathologist, Pathcare laboratories, Cape Town
- Andriette van Jaarsveld, Clinical Pharmacist, MediClinic
Defined Daily Dosage (World Health Organisation)
Cost data do not by themselves adequately tell the story of antibiotic utilisation. Defined Daily Dosage is a World Health Organisation metric for drug utilisation. A DDD is the average maintenance dose of the drug when used for its major indication in adults. Improved understanding of antibiotic overuse (and underuse) is possible using DDDs.
DDDs are thus suitable for:
- Comparisons of drug utilization
- Evaluation of long term trends in drug use
- Assessing the impact of certain events on drug use
In this DDD-NAPPI Crosswalk produced by Discovery Health (last updated November 2013) the DDD column contains the amount of drug in each NAPPI-coded product in relation to the WHO defined daily dosage for that drug. The crosswalk contains over 1200 antibiotic products.
This system provides a tool for assessing the impact of Best Care Always and of other attempts to reduce infection rates and improve prescribing of antimicrobials, in hospital and outpatient settings.
This list excludes topical antibiotics, anti-viral agents (e.g. ARVs) and anti-TB drugs. It includes anti-fungals.
No guarantees of accuracy or integrity are offered. Contribution to the QA process is welcomed.
These “secondary drivers” are derived from research done by IHI and CDC. Each objective could be accompanied by one or more measures, with appropriate tasks and workflow to achieve the objectives.
Promptly identify patients who require antibiotics
Obtain cultures prior to antibiotics
Start treatment promptly
Specify expected duration of therapy
Make antibiotics and start date visible at point of care
Consider local susceptibility before starting therapy
Determine and verify antibiotic allergies – adjust accordingly
No antibiotic combinations without evidence
Right dose and interval
Stop or de-escalate based on results of culture
Adjust when transitions of care or changes in condition
Monitor for toxicity
Provide data on resistance, adverse drug events, C difficile, cost, adherence to recommended practice
Make expertise available to doctors at point of care
External guidelines and references
- Africa Centres for Disease Control and Prevention – Framework for antimicrobial resistance control in Africa. African Journal of Laboratory Medicine, 2018
- Developing core elements and checklist items for global hospital antimicrobial stewardship programmes: a consensus approach. Clinical Microbiology 2018.
- Global core standards for hospital antimicrobial stewardship programs. International perspectives and future directions. Report of the Leading Health Systems Network 2018.
- Uganda Antimicrobial Resistance National Action Plan 2018-2023
- Become an Antibiotic Guardian – make the pledge!
- South African Antibiotic Stewardship Programme – SAASP