CDC Expert Commentary

Three Steps to Antibiotic Stewardship

Arjun Srinivasan, MD


November 15, 2010

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Hello, I'm Dr. Arjun Srinivasan.

I'm the Associate Director of Healthcare-associated Infection Prevention Programs and Medical Director for CDC's Get Smart for Healthcare Program.

I'm happy to speak with you today as part of the CDC Expert Video Commentary Series on Medscape.

Today, I want to talk to you about 3 simple things you can do to improve antibiotic use in hospitals and long-term care facilities.

First, we all know that antibiotic resistance adversely impacts the health of millions of hospitalized patients every year. Inappropriate antibiotic use in hospitals and nursing homes is contributing to this growing problem of resistance and is helping drive the current national epidemic of Clostridium difficile. These are clearly serious problems that are impacting our patients every day -- leading to morbidity and mortality.

Studies have shown that as much as half of all antibiotic use in hospitals is either unnecessary or inappropriate. Fortunately, studies have also shown, repeatedly, that improving antibiotic use can decrease resistance, decrease C. difficile infections, and improve infection cure rates, all while saving healthcare dollars.

Inappropriate antibiotic use is a medication error and we must begin tackling it now.

As a clinician myself, I know that the thought of implementing antibiotic stewardship into an already busy daily routine can seem daunting. But, let's talk about 3 simple things all of us can do to ensure that we are prescribing antibiotic wisely.

Step 1. All antibiotic orders should have 3 pieces of information -- a dose, duration, and indication.

Too often, antibiotics in hospitals are continued unnecessarily simply because we, the clinicians caring for the patient, do not have information indicating why the antibiotics were started in the first place, or how long they were supposed to be continued.

It is certainly harder to stop therapy if you don't know why it was started in the first place.

This challenge is compounded in today's healthcare system where the primary responsibility for patient care is frequently transitioned from one clinician to another.

Ensuring that all antibiotic orders are always accompanied by a dose, duration and indication will help other clinicians caring for the patient to change or stop therapy when appropriate.

Step 2. When placing orders, make certain that they include getting microbiology cultures.

Knowing the susceptibility of the infecting organism can allow you to narrow a broad spectrum therapy, change the therapy to better treat resistant pathogens, or stop antibiotics when the cultures results suggest an infection is unlikely.

Step 3. When your culture results come back in 24-48 hours, let's take an antibiotic time-out.

Stop and reassess therapy. Antibiotics are generally started before a patient's full clinical picture is known. Now that you have additional information including microbiology, radiographic and clinical information, ask yourself -- Is this antibiotic still warranted? Or more importantly, is this antibiotic still effective against this organism?

Now is the time to re-evaluate why you started the therapy in the first place and gather all of the evidence on whether you should change the course of therapy or stop the antibiotics altogether if an infection no longer appears likely.

When the data suggest an antibiotic is needed, this can be a good time to narrow therapy and specify a final duration of therapy.

The primary mission of antibiotic stewardship is to improve patient safety. Ensuring that serious infections are treated properly is an important step in that direction.

Implementing these 3 steps are a simple way to start stewardship in your facility.

If you have already started a stewardship program and would like to go a step further, please see the resources on this page for enhancing your stewardship efforts.

Antibiotics are a shared resource -- and becoming a scarce resource. The solution is not just to look for new antibiotics. Experts agree it could be up to 10 years until we have new antibiotics available for use. Even then, these agents may not be the panaceas we are hoping for, and if we don't improve the way we use antibiotics, we will lose the new drugs too. We must preserve the antibiotics we have now by implementing effective strategies for improving appropriate antibiotic use.

These actions will preserve a precious resource and ultimately save lives.

Web Resources

CDC Get Smart for Healthcare

CDC Get Smart: Know When Antibiotics Work

Arjun Srinivasan, MD is the Associate Director for Healthcare Associated Infection Prevention Programs in the Division of Healthcare Quality Promotion at the Centers for Disease Control and Prevention. Before coming to CDC he was as Assistant Professor of Medicine in the Infectious Diseases Division at the Johns Hopkins School of Medicine where he was the founding director of the Johns Hopkins Antibiotic Management Program and the associate hospital epidemiologist. His primary responsibilities include oversight and coordination of efforts to eliminate healthcare-associated infections. His research and investigative areas of concentration include outbreak investigations, infection control, multi-drug resistant gram-negative pathogens and antimicrobial use. In 2008, he assumed the medical directorship of a new CDC campaign called "Get Smart for Healthcare" which is designed to improve the use of antimicrobials in in-patient healthcare facilities. Dr. Srinivasan has published several articles in peer-reviewed journals on his research in healthcare epidemiology, infection control and antimicrobial use and resistance. He is a member of the Association for Professionals in Infection Control and Epidemiology, the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America.


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