Unit
- Definition: Antimicrobial stewardship (AMS) is a coordinated program that promotes the appropriate use of antimicrobials, including antibiotics, antivirals, antifungals, and antiparasitics, to improve patient outcomes, reduce microbial resistance, and decrease unnecessary costs. It involves selecting the right drug, dose, duration, and route of administration.
- Primary goal: The main objective of AMS is to optimize clinical outcomes while minimizing unintended consequences of antimicrobial use, such as toxicity, selection of pathogenic organisms, and emergence of resistance. This balance is achieved through evidence-based prescribing practices and continuous monitoring.
- Scope of practice: AMS programs typically operate within hospitals, long-term care facilities, and outpatient settings. Activities include prospective audit and feedback, formulary restriction, preauthorization, and guideline development. The scope extends to diagnostic stewardship, which ensures appropriate testing to guide therapy.
- Core components: The CDC identifies seven core elements for hospital AMS: leadership commitment, accountability, drug expertise, action, tracking, reporting, and education. These elements form a framework that can be adapted to various healthcare settings.
- Interprofessional approach: Effective stewardship requires collaboration among infectious disease physicians, clinical pharmacists, microbiologists, infection preventionists, nurses, and hospital administrators. Each team member contributes unique expertise to guide antimicrobial use decisions.
- Patient safety focus: AMS directly impacts patient safety by reducing adverse drug events, preventing Clostridioides difficile infections, and minimizing the risk of superinfections. Programs track metrics such as days of therapy per patient days and antibiotic consumption rates.
- Financial implications: Antimicrobials account for a significant portion of hospital pharmacy budgets. Stewardship programs can reduce antimicrobial costs by 20-30% without compromising care, making them financially sustainable initiatives.
- Regulatory context: The Joint Commission and CMS require healthcare organizations to have antimicrobial stewardship programs in place. Compliance with these standards is mandatory for accreditation and reimbursement, highlighting the operational necessity of AMS.
- AMS implementation often follows a Plan Do Study Act cycle. Initial steps involve forming a multidisciplinary team, reviewing current prescribing patterns, and identifying specific targets for improvement. Subsequent cycles focus on implementing interventions, measuring their impact on predefined metrics, and refining protocols based on observed outcomes.
- A critical component of AMS is diagnostic stewardship, which involves selecting the right diagnostic test at the right time for the right patient. This helps avoid unnecessary antimicrobial use triggered by false positive results or colonization. Strategies include implementing standardized testing algorithms, utilizing rapid diagnostic technologies, and optimizing specimen collection techniques.
- Stewardship efforts extend across transitions of care. When patients move from hospital to home or a long term care facility, clear communication regarding the antimicrobial plan is crucial. This includes documenting the intended duration, indication for therapy, and any planned outpatient parenteral antimicrobial therapy (OPAT) to ensure continuity and prevent unnecessary prolonged treatment.
- Technology plays a vital role in modern AMS operations. Clinical decision support systems integrated into electronic health records can alert providers to potential duplication, inappropriate dosing, or the need for de escalation. Commonly tracked metrics include days of therapy per 1,000 days present (DOT/1000 DP), length of therapy (LOT), and standardized antimicrobial administration ratio (SAAR).
Scope of Practice
Role: Antimicrobial Stewardship Coordinator (Pharmacist)
Within scope:
- Reviewing antimicrobial orders and providing feedback to prescribers
- Developing and updating treatment guidelines based on local antibiogram data
- Analyzing antimicrobial utilization data and reporting to stakeholders
- Conducting education sessions for clinical staff on appropriate prescribing
- Collaborating with microbiology to optimize culture and sensitivity reporting
Outside scope:
- Diagnosing infections or selecting therapy independently without physician input
- Prescribing antimicrobials or changing orders without authorization
- Overriding clinical judgment of the treating physician
- Performing patient assessments or physical examinations
- Taking primary responsibility for patient outcomes
Quick Revision
- Antimicrobial stewardship is a coordinated program to optimize antimicrobial use and combat resistance.
- Core elements include leadership, accountability, drug expertise, action, tracking, reporting, and education.
- Stewardship roles have defined boundaries; coordinators review and advise but do not prescribe.
- Regulatory bodies mandate stewardship programs for accreditation and reimbursement.