IDSA/SHEA Guidelines on Antibiotic Stewardship Released

Susan London

April 14, 2016

New national guidelines on antibiotic stewardship take a more practical approach to the issue, offering pragmatic advice and endorsing programs tailored to each institution's unique situation.

"I hope that these guidelines will set a foundation for programs, both in existence and just being implemented, to really look through this menu and see what works for them," lead author Tamar Barlam, MD, told Medscape Medical News. "And ultimately, what we all hope is that they improve antibiotic use, so that patients have better outcomes and less resistance."

In response to escalating antibiotic resistance, the White House issued an action plan last year to dramatically reduce inappropriate use of these drugs by 2020. One of the approaches outlined is implementation of antibiotic stewardship programs.

An expert panel from the Infectious Diseases Society of America (IDSA) and the Society for Healthcare Epidemiology of America (SHEA) drafted the guidelines, which were published online April 14 in Clinical Infectious Diseases.

The guidelines replace those issued in 2007, which were fairly broad and defined more of a gold standard for a stewardship program, according to Dr Barlam, who is director of the antibiotic stewardship program at Boston Medical Center and associate professor of medicine at Boston University School of Medicine in Massachusetts.

In contrast, the new guidelines focus on individual interventions and stress that programs should tailor interventions based on local issues, resources, and expertise. In addition, the guidelines recommend that antibiotic stewardship programs be led by physicians, including infectious diseases specialists, and pharmacists.

The expert panel drafting the guidelines followed a process whereby they systematically weighed the strength of each recommendation and the quality of evidence behind it, using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. In all, they offer 28 recommendations.

"We really wanted to get across the point that every hospital, every facility really could do an activity that is related to antibiotic stewardship," Dr Barlam commented. "That, of course, fits with the fact that in the next few years, a stewardship program may become a requirement."

The recommendation to use preauthorization of antibiotics and/or prospective review and feedback after an antibiotic has been started is considered essential. "We felt these have to be the cornerstone of every program, although within that, you can individualize it," she noted.

The guidelines put forth the option of syndrome-specific stewardship, which may be more feasible for some programs. "Instead of trying to look at every patient all the time, maybe you just look at pneumonia for a few months, or maybe you just look at urinary tract infections," Dr Barlam explained.

A noteworthy change is expansion of the section on microbiology testing, which now includes information on rapid diagnostic testing. The authors note that rapid testing was not widely available when the guidelines were last drafted, and may go a long way toward reducing inappropriate antibiotic use.

The panel gave most of the recommendations a "weak" rating, even though some of the underpinning interventions had positive results in randomized trials, Dr Barlam noted. "We were looking to see if an intervention had proven effective as a stewardship intervention," she explained. "When you looked at it from that lens, we really had very few recommendations that were strong recommendations."

By highlighting these gaps in the evidence, the guidelines may stimulate research, according to Dr Barlam. "Just seeing [the information] out there in that way could hopefully encourage projects that would help to improve that level of evidence," she concluded.

The authors disclosed various relationships with Pfizer Grants for Learning and Change, Novartis, Actavis Pharmaceuticals, Cubist Pharmaceuticals, Bruker Diagnostics, IDSA, Cardeas, Johnson & Johnson, sanofi aventis, Durata Therapeutics, JAMA Surgery, Oakstone General Surgery, Cepheid, Alere, Cempra Pharmaceuticals, Cerexa, AstraZeneca, RPS Diagnostics, Pfizer, Astellas, Bayer Pharmaceuticals, Premier, Diatherix, the American Institutes of Research, the University of Rochester, Dignity Health, the Pew Charitable Trusts, the CDC Foundation, and the Association of State and Territorial Health Officials.

Clin Infect Dis. Published online April 14, 2016.


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