Antimicrobial Stewardship Strategies: A How-To Guide

Emily Spivak, MD, MHS


June 01, 2016

Editorial Collaboration

Medscape &

Implementing an Antibiotic Stewardship Program: Guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America

Barlam TF, Cosgrove SE, Abbo LM, et al
Clin Infect Dis. 2016;62:e51-e77

Why New Guidelines?

This month, the Infectious Diseases Society of America (IDSA) and the Society for Healthcare Epidemiology of America (SHEA) released recommendations for implementing an antibiotic stewardship program (ASP) in inpatient populations, including long-term care. These guidelines specifically address best approaches to optimize antimicrobial use and measurement strategies.

These guidelines replace the Guidelines for Developing an Institutional Program to Enhance Antimicrobial Stewardship,[1] published in 2007, which delineated ideal stewardship team members, needed resources, and core strategies for ASPs but lacked practical details of how to implement an ASP, specific strategies, and best measures to evaluate impact.

Whereas the revised guidelines reiterate that the cornerstone of any program should be prior authorization and/or prospective audit and feedback, they detail supplemental strategies, including development of syndrome-specific interventions and clinical practice guidelines, use of rapid diagnostic testing, implementing antibiotic timeouts, reducing use of antibiotics associated with Clostridium difficile infection, and addressing antibiotic use in the terminally ill, among others.

Additionally, the authors emphasize that programs should be led by infectious diseases physicians with antimicrobial stewardship training, and they also note the importance of local tailoring of programs based on individual needs, expertise, and available resources.

Stewardship Strategies

One supplemental strategy recommended in the guideline for implementing an ASP is use of stratified antibiograms to expose differences in susceptibilities between units or patient populations that would in turn affect empiric therapy. However, stratification often results in isolate numbers below the minimum number for reporting recommended by the Clinical and Laboratory Standards Institute.

To overcome this limitation, Campigotto and colleagues[2] compared susceptibility data for two different intensive care units (ICUs) using a traditional method of combining data vs a rolling-average report that pooled 2 years of data for each ICU separately. Comparing the rolling-average method with the traditional method, the investigators found significant differences in susceptibilities between ICUs in 50% of the organism-antimicrobial combinations evaluated. Their findings led to changes in recommended empiric therapy and suggested that a rolling-average method combining multiple years for one unit may facilitate development of stratified antibiograms and expose clinically relevant differences in susceptibility profiles between units.

Performing urine cultures reflexively only in the presence of significant pyuria is often suggested as a means of minimizing urine cultures and unnecessary treatment of asymptomatic bacteriuria; however, the impact of this testing methodology is unknown. To address this question, Sarg and colleagues[3] performed a quasi-experimental study evaluating the effect of a change in urine culture–ordering practice in adult ICUs whereby urine cultures were only performed when pyuria (> 10 white blood cells per high-powered field) was detected. Population-level antimicrobial use (days of therapy per 1000 patient-days), urine cultures performed, and bacteriuria were assessed pre- and post-intervention. The investigators found statistically significant reductions in aggregate monthly rates of urine cultures performed, bacteriuria, and new antimicrobial starts for urine culture results, but no change in total days of therapy. Despite reducing new antimicrobial starts for urine culture results at the patient level, this approach did not affect overall days on therapy, suggesting minimal impact as a stewardship intervention and the need to assess other drivers of antimicrobial use.

The new guidelines recommend the use of rapid viral testing for respiratory pathogens as an approach to reduce inappropriate antibiotic use. A recent study published in the Journal of Pediatrics[4] supports this recommendation. Subramony and colleagues retrospectively compared the use of antibiotics, chest radiographs, and isolation precautions for patients aged < 18 years, who were tested for respiratory pathogens pre- and post-introduction of a multiplex polymerase chain reaction (PCR) assay for identification of respiratory pathogens. Patients in the PCR group had more positive tests (42.4% vs 14.4%, P < .01), received fewer days of antibiotics (4 vs 5 median antibiotic days, P < .01), underwent fewer chest radiographs (59% vs 78%, P < .01), and were placed in isolation longer (20 vs 0 median isolation-hours, P < .01) compared with the non-PCR group. These data underscore the role that rapid diagnostics play in reducing not only unnecessary antimicrobial use but also overall healthcare resource utilization, with the added benefit of providing patients and providers with a diagnosis.



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