Antimicrobial stewardship: impact and challenges.

Susan Hadley, MD This month’s Special Topic Focus in Infectious Diseases encompasses antimicrobial stewardship and its health care impact and challenges. In the past several decades, the marked increase of antimicrobial-resistant pathogens worldwide has resulted in worse patient outcomes, higher costs, and longer hospital stays. Although the concept of rational use of antimicrobials is not new, it’s imperative is intensely felt in this era of increasing antimicrobial resistance and decreasing drug development. The 2004 Infectious Diseases Society of America’s document “Bad Bugs Need Drugs” depicted an alarming decrease in the pharmaceutical industry’s research and development of new drugs coinciding with significant increases in bacterial resistance to available antimicrobials. By 2009, the updated document identified 6 pathogens with markedly reduced antimicrobial susceptibilities, providing little ESKAPE (Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter species) to those afflicted. In response to poorer outcomes, reduced pathogen susceptibility, and increasing costs, antimicrobial stewardship programs (ASPs) developed in the 1990s to varying degrees on an international level. They currently have a much wider prevalence, primarily in the acute care setting. The primary goal of a stewardship program is to maximize clinical outcomes while minimizing the unintended consequences of antimicrobial use, such as toxicity, selection of pathogenic organisms, and emergence of resistance. Reduction of health care costs without affecting quality of care is a secondary aim of the program. The recognition that misuse of antimicrobials affects the society of patients and not just an individual patient by influencing the health care setting microflora and risk of transmission of resistant organisms empowered ASP development. Moreover, an approach to readily detect, prevent, and treat multidrug-resistant organisms was deemed necessary and thus requiring a multidisciplinary team. In fact, California Senate Bill 739, passed in 2006, mandated that the California Department of Public Health require that all general acute care hospitals develop a process for monitoring and evaluating the appropriate use of antibiotics by 2008. The traditional stakeholders of the programs are hospital administrators, infectious disease (ID) physicians, pharmacists with specialized ID training, microbiologists, infection control practitioners, health care epidemiologists, and hospital information technology personnel. Yet hospitalists, who now care for approximately 50% of inpatients, serve perhaps an underrecognized central role in such programs. Although it is widely accepted that ASPs serve a valuable quality improvement role, not all health care settings are able to develop a formal program. Barriers may be financial, pushback from physicians, or lack of appropriate personnel. Strategies used by ASPs consist for the most part of either prospective audit of antibiotic orders with feedback to the clinician and intervention or formulary restriction and preauthorization of specific agents. These interactions are grounded in the promotion of education to all health care personnel be it face-to-face or consultative via telephone or Internet. In this issue, the article by Doron et al describes the current state of ASPs in US hospitals of the Premier Healthcare Alliance and barriers to their implementation. Although hospitals may not identify themselves using a specific ASP, most surveyed use techniques aimed at optimizing antimicrobial use. Barriers to implementation included staffing constraints, funding, insufficient medical buy-in, and other priorities, and factors associated with