1

Running Head: ANTIMICROBIAL STEWARDSHIP PROGRAMS: EFFECTIVE OR NOT?

Antimicrobial Stewardship Programs: Effective or Not?

Lindsay Scholten
Ferris State University

ANTIMICROBIAL STEWARDSHIP PROGRAMS: EFFECTIVE OR NOT?

In 1945 Alexander Fleming, the discoverer of penicillin, warned that it posed a large
potential for misuse and would lead to the spread of resistant mutants (Paskovaty, Pflomm,
Myke, & Seo, 2005, p. 1). Methicillin-resistant Staphylococcus aureus (MRSA) was once
considered a nosocomial infection (Nicolau, 2011). Data from the Minnesota Department of
Health showed an increase of community-acquired MRSA cases from 11% in 2000 to 33% in
2005 (Nicolau, 2011). Antibiotic resistance is making infections more difficult to treat and new
drugs are not being developed fast enough (Nicolau, 2011). The Infectious Disease Society of
America (IDSA) and the Society for Healthcare Epidemiology of America (SHEA) have together
published recommendations for preventing antimicrobial resistance (Paskovaty et al., 2005).
Their recommendations are the basis for antimicrobial stewardship programs (ASP).
Antimicrobial stewardship programs will be discussed, including why they are needed, what they
entail, and the impact they make.
It is estimated that 50% of antibiotic use in humans is inappropriate (Paskovaty et al.,
2005). Antibiotics are the second most prescribed class of drugs (Fishman, 2006). This
inappropriate use is leading to increases in patient mortalities, hospital stays, healthcare costs,
and organism resistance (Nicolau, 2011). Nicolau (2011) says the organisms are not changing
but their resistance is. Huang and Yealy (2013) explain how resistance in bacteria occurs
naturally even when not directly exposed to antibiotics, and that indiscriminate use of
antibiotics can alter the slope of resistance acquisition (p. 78). A particular bacterium,
Acinetobacter baumannii, is resistant to at least 3 different antibiotic classes (Nicolau, 2011).
Rello (2013) emphasizes the importance of switching to narrower spectrum antibiotics once
organisms are identified. Nicolau (2011) and Rello (2013) agree that prompt and appropriate
therapy reduces mortalities and lengths of stays in the hospital. The inappropriate use of

ANTIMICROBIAL STEWARDSHIP PROGRAMS: EFFECTIVE OR NOT?

antibiotics is costing facilities more than it should. Thirty percent of a pharmacys budget is
spent on antibiotics (Vettese et al. 2013). With bacteria developing multi-drug resistance, it is
crucial for practitioners to re-evaluate their prescribing practices and healthcare facilities to
implement stewardship programs.
The primary goal of an ASP is to improve clinical outcomes in patients (Rello, 2013), and
to prevent or reduce acquired resistance (Owens, 2008). A secondary goal is to reduce costs
(Rello, 2013). Stewardship programs emphasize optimal antibiotic use by ensuring the
appropriate drug, dose, and duration is prescribed (Fishman, 2006). Nicolau (2011) adds the
complexity of the patients illness should be considered when prescribing antibiotics. Programs
might aim to shorten the duration of therapy or to switch the drug route from intravenous to oral
decreasing costs and the risks of phlebitis and infection (Paskovaty et al., 2005). ASPs are a
multidisciplinary collaboration typically involving an infectious disease physician and a
pharmacist (Paskovaty et al., 2005). Gillespie, Rodrigues, Wright, Williams, and Stuart (2013)
think nurses should also be educated on antibiotic appropriateness to be an effective part of the
team. It is the practitioners job to decide when and how to use antibiotics, with the goal to rid
infection, yet maintain the drugs effectiveness (Huang & Yealy, 2013).
Stewardship programs should be customized to fit the needs of an organization
(Paskovaty et al., 2005). Facilities must track organisms and identify trends (Owens, 2008).
Formularies should be used to limit the selection of antibiotics (Huang &Yealy, 2013). Prior
approval and restricted access to certain antibiotics is also recommended (Owens, 2008).
Computer programs are beneficial for tracking information about drug selection, dose, side
effects, and can link laboratory data to pharmacy information (Fishman, 2006). Typically a
broad spectrum drug is prescribed until organisms are identified. Obtaining cultures is important
so the most narrow and appropriate antibiotics are prescribed (Rello, 2013). Choosing the

ANTIMICROBIAL STEWARDSHIP PROGRAMS: EFFECTIVE OR NOT?

appropriate drug requires knowledge, so education is essential in an ASP (Fishman, 2006).
Paskovaty et al. (2005) emphasize that education is important, but the programs effectiveness
depends on the motivation of the clinician to make and sustain a behavioral change (p. 3).
With any change there will be challenges. Since stewardship programs are a newer
concept, there are few studies to determine how effective they really are (Fishman, 2006).
Delays in treatment while choosing appropriate drugs can be harmful to seriously ill patients
(Owens, 2008). Outpatient facilities tend to err on the side of caution and prescribe antibiotics
because they cannot monitor patients, so delaying treatment is not an option (Huang & Yealy,
2013). Determining effectiveness of education within a stewardship program can be difficult due
to the variety of approaches and the lack of uniform feedback (Danaher, Milazzo,Lagasse &
Lane, 2009). Gillespie et al. (2013) say there is little agreement on the approach to
implementing programs. Nicolau (2011) explains that the financial savings from a stewardship
program are insignificant, only about 5% of total healthcare costs. Owens (2008) emphasizes
that ASPs are only one aspect of reducing resistance. Infection control and environmental
services also play an important role in reducing the spread of resistant organisms (Owens, 2008).
Antimicrobial stewardship programs have been proven effective in both inpatient and
ambulatory settings. A medical ICU at Vidant Medical Center implemented an ASP focused on
antibiotic appropriateness and collaboration with infectious disease physicians (Rimawi, Mazer,
Siraj, Gooch, & Cook, 2013). They had a reduction in the length of stays from 10.29 days to
7.78 days (Rimawi, Mazer, Siraj, Gooch, & Cook, 2013). The mortality rate of the unit did not
change significantly, but they reduced the spending on antibiotics by $22,486 in a 3 month
period (Rimawi et al., 2013). An inpatient facility in South Korea had a 33.2% decrease in
MRSA blood stream infections after implementing a stewardship program (Kim et al., 2013).
Their program included education on hand washing, making it difficult to determine the direct

ANTIMICROBIAL STEWARDSHIP PROGRAMS: EFFECTIVE OR NOT?

impact from antibiotic use (Kim et al., 2013). A study done in an outpatient center showed a
decrease in antibiotic use from 26.8% to 14.3% in children with acute respiratory tract infections
(Gerber et al., 2013). Off-guideline antibiotic use was reduced significantly when the facility
implemented an ASP focused on education along with an audit and feedback system (Gerber et
al., 2013, p. 2349). A recent study showed more antibiotics were prescribed for patients with
acute respiratory infections in emergency departments than in primary care facilities (Huang &
Yealy, 2013). Formal programs are needed to ensure compliance and consistency in all
departments (Owens, 2008). Vettese et al. (2013) found that ASPs can reduce costs by
$200,000-$900,000 a year, depending on the size of the institution.
Stewardship programs cannot prevent all resistant bacterial infections, but until new
drugs are available they are one way to slow resistance. Paskovaty et al. (2005) say it is thought
that optimizing antibiotic use will minimize selective pressure and maintain or improve bacterial
susceptibilities (p. 8). Identifying organisms and prescribing appropriate antibiotics has been
shown to reduce infection-related morbidity and mortality (Nicolau, 2011, p. S1).

Other lab

results may offer hope in the determination of bacterial versus viral infection. Procalcitonin is
found in the blood and is generally elevated in bacterial infection but low in viral infection
(Huang & Yealy, 2013). Antimicrobial stewardship programs are not a cure-all for bacterial
resistance and many other factors need to be considered to fix the problem, but ASPs are a step
in the right direction.

ANTIMICROBIAL STEWARDSHIP PROGRAMS: EFFECTIVE OR NOT?

References
Danaher, P. J.,U.S.A.F.M.C., Milazzo, N. A.,U.S.A.F.B.S.C., Kerr, K. J.,U.S.A.F.B.S.C., Lagasse,
C. A.,U.S.A.F.B.S.C., & Lane, J. W.,U.S.A.F.M.C. (2009). The antibiotic support team-A
successful educational approach to antibiotic stewardship. Military Medicine, 174(2), 201-5.
Retrieved from http://search.proquest.com/docview/217049796?accountid=10825
Fishman, N. (2006). Antimicrobial stewardship. The American Journal of Medicine, 119 (6A),
S53-S61. doi: 10.1016/j.amjmed.2006.04.003
Gerber, J., Prasad, P., Fiks, A., Localio, A., Grundmeier, R., Bell, L., &Zaoutis, T. (2013). Effect
of an outpatient antimicrobial stewardship intervention on broad-spectrum antibiotic
prescribing by primary care pediatricians: a randomized trial. JAMA: Journal Of The
American Medical Association, 309(22), 2345-2352. doi:10.1001/jama.2013.6287
Gillespie, E., Rodrigues, A., Wright, L., Williams, N., & Stuart, R. L. (2013). Improving antibiotic
stewardship by involving nurses. American Journal Of Infection Control, 41(4), 365-367.
doi:10.1016/j.ajic.2012.04.336
Huang, D., & Yealy, D. (2013). Antibiotic stewardship-what should I do tomorrow?. Annals Of
Emergency Medicine, 62(1), 78-79. doi:10.1016/j.annemergmed.2013.02.019
Jenkins, T., Stella, S., Cervantes, L., Knepper, B., Sabel, A., Price, C., & Burman, W. (2013).
Targets for antibiotic and healthcare resource stewardship in inpatient community-acquired
pneumonia: a comparison of management practices with National Guideline
Recommendations. Infection, 41(1), 135-144. doi:10.1007/s15010-012-0362-2
Kim, Y., Kim, M., Song, J., Ahn, J., Oh, D., Kweon, O., & ... Choi, J. (2013). Trend of methicillinresistant Staphylococcus aureus (MRSA) bacteremia in an institution with a high rate of
MRSA after the reinforcement of antibiotic stewardship and hand hygiene. American
Journal Of Infection Control, 41(5), e39-43. doi:10.1016/j.ajic.2012.12.018
Nicolau, D. (2011). Current challenges in the management of the infected patient. Current Opinion
in Infectious Diseases, 24, S1-S10. doi: 10.1097/01.qco.0000393483.10270.ff

ANTIMICROBIAL STEWARDSHIP PROGRAMS: EFFECTIVE OR NOT?

Ostrowsky, B., Sharma, S., DeFino, M., Guo, Y., Shah, P., McAllen, S., & ... Bhalla, R. (2013).
Antimicrobial Stewardship and Automated Pharmacy Technology Improve Antibiotic
Appropriateness for Community-Acquired Pneumonia. Infection Control & Hospital
Epidemiology, 34(6), 566-572. doi:10.1086/670623
Owens, R. (2008). Antimicrobial stewardship: concepts and strategies in the 21st century. Diagnostic
Microbiology and Infectious Disease 61, 110-128. doi:10.1016/j.diagmicrobio.2008.02.012
Paskovaty A., Pflomm, J., Myke, N., & Seo, S. (2005). A multidisciplinary approach to
antimicrobial stewardship: evolution into the 21st century. International Journal of
Antimicrobial Agents 25(1), 1-10. DOI: 10.1016/j.ijantimicag.2004.09.001)
Rello, J. (2013). Antibiotic stewardship in hospital-acquired pneumonia. Chest, 143(5), 1195-1196.
doi:10.1378/chest.12-2729
Rimawi, R., Mazer, M., Siraj, D., Gooch, M., & Cook, P. (2013). Impact of regular collaboration
between infectious diseases and critical care practitioners on antimicrobial utilization and
patient outcomes. Critical Care Medicine 41(9), 2099-2107.
doi:10.1097/CCM.0b013e31828e9863
Rohde, J. M., Jacobsen, D., & Rosenberg, D. J. (2013). Role of the hospitalist in antimicrobial
stewardship: A review of work completed and description of a multisite collaborative.
Clinical Therapeutics, 35(6), 751-757. doi:10.1016/j.clinthera.2013.05.005
Sick, A. C., Lehmann, C. U., Tamma, P. D., Lee, C. K., & Agwu, A. L. (2013). Sustained savings
from a longitudinal cost analysis of an internet-based preapproval antimicrobial stewardship
program. Infection Control & Hospital Epidemiology, 34(6), 573-580. doi:10.1086/670625
Vettese, N. N., Hendershot, J. J., Irvine, M. M., Wimer, S. S., Chamberlain, D. D., & Massoud, N.
N. (2013). Outcomes associated with a thrice-weekly antimicrobial stewardship programme
in a 253-bed community hospital. Journal Of Clinical Pharmacy & Therapeutics, 38(5),
401-404. doi:10.1111/jcpt.12079