Good antimicrobial stewardship in the hospital: fitting, but flagrantly flagging.

There are two general approaches to preventing or reversing antimicrobial resistance in the hospital setting. Prevention of transmission of resistant organisms from patient to patient is the traditional infection control approach that, if practiced perfectly, would resolve the problem of nosocomial infection due to resistant organisms. It is the stuff of which all good hospital epidemiologists and infection control professionals are made. The second approach originates from the observation that the emergence of antimicrobial resistance is related to the use of antimicrobials. This approach is built on the premise that antimicrobial use (which is highly beneficial in the treatment of patients) is less than optimal and that, by improving (or reducing) use, there will occur a corresponding prevention or decline of antibiotic resistance. Both approaches were advocated in the “Guidelines for the Prevention of Antimicrobial Resistance in Hospitals” issued jointly in 1997 by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA).1 The guideline proposed four methods to influence antimicrobial use in order to prevent antimicrobial resistance. The first of these methods, optimal use of all antimicrobials, is the essence of what the guideline calls “good antimicrobial use stewardship”: the practice of treating patients with the most effective, least toxic, and least costly antimicrobial for the precise duration of time needed to cure or prevent an infection. Some would call it the apple-pie–and–motherhood approach to antimicrobial prescribing. Clinical guidelines, treatment algorithms, and consultations provide the guidance for good stewardship. The second method recognizes the difficulty of accomplishing the ideal of good stewardship and advocates restriction, removal, or control of selected antimicrobials to reduce or prevent resistance. It is generally conceded to be the most effective method to change antimicrobial usage.1 The third proposed method, antimicrobial cycling, a preemptive form of cyclic restriction, was the subject of a January 2000 Supplement to this Journal, edited by Joseph John, Jr, MD, one of the authors of the SHEA/IDSA prevention guideline.2 The fourth suggested method, use of combinations of antimicrobials, is the basis for prevention of resistance development in the treatment of tuberculosis and human immunodeficiency virus infections, but has received little consideration for other hospital antimicrobial use. In this issue of Infection Control and Hospital Epidemiology, Lawton and colleagues report the results of a survey of 47 Intensive Care Antimicrobial Resistance Epidemiology (ICARE) hospitals to determine the extent of their antimicrobial-use improvement practices.3 The questions were directed at methods 1 and 2 of the SHEA/IDSA guideline, querying the hospitals on practices (clinicalpractice guidelines) in place to support and improve good stewardship and on the presence of formulary controls and restrictions or limitations (stop orders) on antimicrobial use. Questions specifically regarding antimicrobial-cycling policies and use of combination therapy were not asked. One of the most impressive aspects of the survey is the 100% completion rate. The only antibiotic practice found in all 47 hospitals was the presence of a pharmacy formulary, which in 4 of the hospitals was the only practice in place. Unfortunately, the presence of a formulary does not indicate the degree to which antimicrobial use is constrained in an institution. Restrictions on the use of any antimicrobial were in place in 40% of the hospitals. It is not clear that the formulary restrictions were in place to improve antibiotic use, since much of formulary restriction traditionally has had cost control as its major goal. Nonetheless, the restrictions were in place, and automatic stop orders were in place in 60% of hospitals. Finally, in the