Over the next year, we are hoping to institute a formal antimicrobial stewardship program at St. Joseph Hospital. To quote, from the Infectious Disease Society of America's recently published guidelines (see reference below, for full details):

The primary goal of antimicrobial stewardship is to optimize clinical outcomes while minimizing unintended consequences of antimicrobial use, including toxicity, the selection of pathogenic organisms (such as Clostridium difficile), and the emergence of resistance. (p. 159)

All of us, have by now, no doubt cared for a frail, elderly person with their second or third relapse of C. difficile colitis, or the patient with a urinary tract infection treatable only by intravenous antibiotics. Rational use of antimicrobials can go a long way toward preventing these difficult situations. 
 
In addition, by aggressively switching patients from costly, broad-spectrum antimicrobials to less expensive, narrow-spectrum agents, we help stretch our ever-shrinking health care dollar. Wherever antimicrobial stewardship programs have been instituted, from large, academic medical centers, to smaller community hospitals, cost-savings are almost immediate, averaging 30% with respect to the antimicrobial budget. More appropriate care for less money, what could be better?
 
There are several ways that antimicrobial stewardship can be instituted.  One such method is to "tighten up" the formulary.  Some antibiotics may be eliminated completely; others may fall under greater restrictions with respect to initial prescribing.  More aggressive IV to p.o. conversion, based upon specific clinical parameters, also helps limit antibiotic exposure, and may permit removal of indwelling venous access devices (and hence potentially reduce the risk of catheter-associated bloodstream infections) and provide for earlier hospital discharge.  Additionally, a daily prospective audit of all inpatients receiving antimicrobials, with pharmacist and infectious disease physician feedback and intervention has also been shown to be both educational and clinically relevant.
 
There are several changes to our current antimicrobial prescribing system which will need to be made, if this type of program is to be a success.  Some of these changes relate to information technology and pharmacy staffing, and these are forthcoming.  Other changes require alterations in prescribing habits, which are often the more difficult challenge.  Obviously, there is a learning curve, here, but most programs have found that this only takes a short while to sort out, and once clinicians are used to it, most find that it's not unduly restrictive and welcome the benefits to their patients. We welcome your advice and feedback as we move forward with this initiative.  Please feel free to contact me, or one of my partners, should you have any questions.
 
Alex Granok, MD, FACP
Infectious Disease Associates
 
Reference:
Dellit, TH, et al.  Guidelines for Developing an Institutional Program to Enhance Antimicrobial Stewardship.  Clinical Infectious Diseases 2007; 44: 159-77. 

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