Improving Prescribers to Advance Antimicrobial Stewardship

In an era of ever-increasing antibiotic resistance, antimicrobial stewardship plays a vital role in improving patient outcomes and ensuring the appropriate use of these agents. In this issue of Clinical Infectious Diseases, Hamilton et al acknowledge that most formalized antimicrobial stewardship programs (ASPs) do not currently employ a routine intervention with the antibiotic prescriber at the point of prescription [1]. These authors suggest that point-of-prescription interventions with frontline healthcare providers have the potential to expand existing ASPs and provide alternative approaches to performing stewardship at institutions without ASPs. While it is true that a multidisciplinary team often assumes the responsibility for direct patient care in the inpatient setting, the overwhelming majority of prescriptions, including those for antibiotics, are written by physicians. Thus, if we are to place the responsibility of appropriate antimicrobial use on physicians at the point of prescribing, it is pertinent to examine the perceptions and knowledge of these prescribers toward stewardship and appropriate antimicrobial use. In 2013, Abbo et al conducted a multicenter electronic survey evaluating the perceptions and knowledge of antimicrobial education and prescribing of fourthyear medical students from 3 medical schools in the United States [2]. Only 40% of the respondents were even familiar with the term “antimicrobial stewardship,” and 90% reported that they would like more education on the appropriate use of antimicrobials. Just 15% had completed a clinical infectious diseases rotation while in medical school, and <33% understood the correct spectrum of antimicrobials and felt well prepared to streamline and de-escalate antimicrobial therapy. The students’ mean correct knowledge score on an assessment using 11 clinical vignettes was 51%. Although this survey evaluated medical students with limited clinical experience, similar results have been demonstrated in surveys of inpatient internal medicine physicians [3]. In one survey, 97% of physicians believed that widespread and inappropriate use of antibiotics was an important cause of resistance, and only 66% believed that a reduction in antimicrobial use was an effective remedy, compared with the 95% of infectious diseases physicians who believed this was an effective approach [3]. In a similar survey, 94.8% of clinicians agreed that antimicrobial resistance was a problem nationally, whereas only 65.3% agreed that it was a problem within their own practice [4]. They reported that practicing antimicrobial control was one of the most important steps toward preventing antimicrobial resistance but also cited it as the step having the most barriers to implementation. A lack of knowledge and education regarding antimicrobial use and resistance was cited by 46% of clinicians in the focus group as a barrier to preventing resistance [4]. If we are to rely on prescribers to be stewards of our antibiotics, improve patient outcomes, and decrease antimicrobial resistance, a 2-tiered approach may need to be considered. The first is to create a robust antimicrobial stewardship effort that involves a multifaceted approach built around core strategies that do not rely solely on physician practices at the point of antibiotic prescribing. As demonstrated in the pilot study by Hamilton et al [1], the antibiotic flowsheet rarely resulted in an intervention unless the flowsheet was implemented by a pharmacist who was not doing the prescribing. An effect on antimicrobial prescribing was almost never reported when the prescribers themselves were responsible for completion of the flowsheet. Hamilton et al suggest that a point-ofprescribing intervention could supplement an existing ASP or be a strategy for Received 5 January 2015; accepted 7 January 2015; electronically published 16 January 2015. Correspondence: Larry H. Danziger, PharmD, FIDSA, University of Illinois at Chicago, College of Pharmacy, 833 S Wood St, Rm 164, M/C 886, Chicago, IL 60612 (danziger@uic.edu). Clinical Infectious Diseases 2015;60(8):1259–61 © The Author 2015. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please e-mail: journals. permissions@oup.com. DOI: 10.1093/cid/civ021