Antibiotics and Adverse Events

The Role of Antimicrobial Stewardship Programs in 'Doing No Harm'

Karri A. Bauer; Ravina Kullar; Mark Gilchrist; Thomas M. File Jr.


Curr Opin Infect Dis. 2019;32(6):553-558. 

In This Article

Role of Antimicrobial Stewardship Programs in 'Doing No Harm'

The Institute of Medicine's (IOM) first Quality Chasm report, To Err is Human: Building a Safer Health System stated that medication-related errors were a significant cause of morbidity and mortality and accounted for more than 7000 deaths annually.[11] Building on this work and previous IOM reports, the IOM put forth a report on medication safety, Preventing Medication Errors. This report emphasized the importance of reducing medication errors, continuing monitoring for errors, and providing clinicians with decision-support and information tools. Among the most common classes of medications cited in the report due to their association with ADEs were antibiotics. In a recent evaluation, among 1488 adult patients receiving systemic antibiotic therapy, 298 (20%) patients experienced at least one antibiotic-associated ADE.[12] Fifty-six (20%) nonclinically indicated antibiotic regimens were associated with an ADE. Aminoglycosides, parenteral vancomycin, and trimethoprim-sulfamethoxazole were associated with the highest rates of ADEs at 21.2 episodes per 10 000 person-days. Antibiotics most frequently associated with CDI were third-generation cephalosporins, cefepime, and fluoroquinolones.

Antibiotics are associated with a variety of toxicities, including specific-drug related adverse events, and the development of multidrug-resistant infections and CDI. One potential solution to mitigate the negative consequences associated with antibiotic use is the implementation of ASPs. ASPs are recommended by the CDC, European Centre for Disease Prevention and Control and the WHO in response to the misuse of antibiotics.[13,14] The primary goal of ASPs is to optimize the appropriate usage of antibiotics to improve clinical outcomes while minimizing unintentional consequences of use, including emergence of resistance, toxicity, selection of pathogenic bacteria (e.g., C. difficile).[15]

The effectiveness of ASPs in the reduction of pathogenic bacteria has been well documented. Specifically, AMS initiatives have been shown to be highly effective in decreasing CDI rates.[16–18] Data from the United Kingdom revealed significant reductions in CDI associated with decreases in targeted antibiotic use.[16] Additional studies have demonstrated the ability of ASPs to decrease the incidence of multidrug-resistant infections. Cook et al.[19] showed that restricting ciprofloxacin use improved the susceptibility of Pseudomonas aeruginosa to the Group 2 carbapenems, such as imipenem or meropenem. A reduction by 90% in the use of ciprofloxacin between 2000 and 2010 led to a concurrent reduction (25% to 10–15%) in the proportion of carbapenem-resistant P. aeruginosa. Further, Baur et al.[20] reviewed 32 studies published from 1 January 1960 to 31 May 2016 to evaluate how ASPs affected the incidence of infection and colonization with multidrug-resistant (MDR) bacteria and C. difficile among inpatients. The authors noted that in hospitals with ASPs, Gram-negative bacteria incidence fell by more than half (51%; P < 0.0001), extended-spectrum beta-lactamase-producing Gram-negative bacteria incidence fell by 48% (P = 0.0428), Methicillinresistant Staphylococcus aureus decreased by 37% (P = 0.0065) and the incidence of C. difficile fell by nearly one third (32%; P = 0.003).

Despite the well documented benefits of AMS, there remains additional opportunities for ASPs to significantly improve patient safety by leading a collaborative effort to reduce antibiotic-associated ADEs, including drug-specific events and the development of multidrug-resistant infections and CDI. These important patient safety initiatives will allow ASPs to continue to generate support among hospital administrators, clinicians, policy makers, and patients. In the past, ASPs have focused on cost savings as primary justification. However, with an increased focus in healthcare on quality, safety, and outcomes data as key components of reimbursement, there is an opportunity to refocus the value of ASPs from only cost savings to quality metrics such as preventing antibiotic-associated ADEs and development of MDR organism infections and CDI.