The current era is an era of rampant drug resistance. For organization like high end tertiary care that are performing high end surgeries, transplants and oncology related work where there is immunosuppressive therapies, probably the challenges are multiplying with times. On the other end, there are chronic diseases and morbidities due to diseases like diabetes are increasing due to high population, eating habits and other social and economic factors. One of the frequent complications in diabetes is infections which require antibiotics therapy and they need repeated antibiotics therapy due to repeated admissions due to one or other reasons.
Similar is scene of hematology and oncology related patients who need frequent admissions in hospitals.
Antibiotic use is not only common in medical industry but also in pharmaceutical, research, veterinarian and food industry where they are used as growth promoters and suppress any impending threats due to infections whether in poultry, dairy industry or other animal related industries.
Stewardship compromises a common list of processes which are implemented as an accountable and responsible care giver by anyone who is involved in prescribing, dispensing or administering antibiotics.
It is a complex process which involves multiple stakeholders starting from prescribing consultants, resident doctors, dispensing units like pharmacy whether in hospital or in community and nurses who are administering antibiotic doses or DOTS observer or any one like patient themselves or their keens. It is multimodality and multidisciplinary efforts to be responsible for actions which are related to antibiotics. Other important stakeholders are government policies, FDA policy on sanctioning new discoveries and overall control of pharmaceutical industry and perspective of pharmaceutical industry which are manufacturing antibiotics and supply chain for antibiotics.
Pharmaceutical role is major because the quality, quantity and pharmacokinetic parameters like bioavailability are very important for medicines like antimicrobials. Clinical microbiologist can just not remain as laboratory consultant but may act as overall in charge for implementation of antimicrobial stewardship program. They can be one point of contact between multiple stakeholders and probably guide the program. Similar help can be provided by intensive care expert and senior physicians.
When it comes to decision making for dosing practices, it is important to understand pharmacokinetic and pharmacodynamic properties of antibiotics. what is type of antibiotic, what is preferred route, what is suitable dose appropriate for age and what is route by which is excreted and what are dose adjustments In conditions like renal insufficiency, liver disease, chronic or acute care settings, pregnancy, children and neonates, certain special conditions like obesity and elderly age. Probably here the institution has to spend more for hiring an appropriate expert for same who is clinical pharmacist.
The pillar for guiding empiric therapy will be the available hospital specific guidelines which are available from microbiology data which is system wise and systematically showing major bugs, their sensitivity pattern and site of infection. Usually policy must include guidance for surgical prophylaxis, urinary tract infections (UTI), Respiratory tract infections (RTIs), Blood stream infections (BSIs), Skin and soft tissue infections (SSTIs) and intra abdominal infections. (Desirable)
Microbiology laboratory must be equipped with basic identification and susceptibility instruments and there should be appropriate provision for doing broth micro dilution test for colistin as the automated systems are not validated for colistin results. Some of indirect markers of infectious diseases like ESR, CRP levels, PCT levels etc. should be available. Serum markers for fungal infections are desirable in view of increased mortality and delayed diagnostic confirmation in view of invasive fungal infections. However it all depends upon scope of services of organization to decide what to include as diagnostic modality as per patient population which they are catering to. Antibiotic sensitivity data has become more reliable with systematic procedures and reproducible results. Another important thing is standardized guidelines are available for performing susceptibility testing like CLSI and EUCAST which are updated on regular basis thus helping and integrating with clinical decision making.
Some of recent advances in diagnostics are really tools which can improve laboratory performance drastically which are PCR based techniques, sequencing and PNA-FISH. The turnaround times are drastically reduced if any of new methods are introduced. This can significantly bring down costs of empirical therapy which are broad spectrum and high end or reserved antibiotics. Long term effect of such diagnostic modality may be they may even be able to reduce drug resistance which may be happening due to wider use of antibiotics and exposure of antibiotics in acute care settings.
Once confirmed, there is de-escalation step where in a specific drug is given as per sensitivity pattern, which is narrow range and as per culture susceptibility test targeting pathogen causing infection. Another word of caution is dealing with contamination and colonizers. Clinicians role is important in deciding appropriate samples to be sent for culture and sensitivity and other ancillary tests like acute phase reactants. Many times, there is ambiguity in diagnosis, so multiple tests are ordered which reduces probability of detection. Another important thing is sending cultures before initiation of antibiotic therapy which improves detection rates. Role of point of care testing is important in this era however there are challenges which are high cost, performing quality control and assurance of test results when performed in acute care settings. Danger of misdiagnosis is abuse and misuse of precious medicines like antimicrobial agent which should be prevented in any given settings as important part of stewardship program.
Antimicrobial stewardship in an organization needs attention by all stakeholders which are clinicians, pharmacists, administrators, patients, nurses and supporting teams. There should be committee for antimicrobial stewardship. If no definitive committee can be formed, then infection control committee can act as parenting committee or may as well combined together as the majority of stakeholders are similar. Committee can formulate antibiotic policy, put formulary restriction for use of specific use of antibiotics and pre authorization whether needed or not for issuing antibiotics. There will be supportive framework from nursing, pharmacy and information technology end for regular scrutiny of dispensed, administered and issued antibiotics which can be tracked and analyzed specialty wise, consultant wise, department wise and unit wise. Restricted antibiotics can be alerted to antimicrobial stewardship committee and appropriate authorization if obtained by members of committee, and then only antibiotics should be administered. In many emergencies, these can never be possible; in such cases probably explanation can be given by ordering physician for use of antibiotics which are restricted.
Role of administrators is in providing appropriate resources i.e. manpower, money and material so that teams can perform effectively. Also administrator can evaluate performance indirectly by looking at cost saving like reduced length of stay and reduced consequences of antibiotic misuse like antimicrobial resistance by introduction of systems related to antimicrobial stewardship implementation.
There is also important role of nurses who are mostly involved in direct patient care. They can literally act as means of education for patients and relatives, foresee the adverse effects of antibiotics administration and improve pharmacovigilance and additionally can act as point of contact for AMS team and consultants. They are important also in implementation of barrier nursing techniques and isolation precautions for the patients who are harboring multidrug resistant organisms (MDROs). The nurses can supervise doses and can actually supervise duration of therapy. Also serve as important personnel in switching from intra venous to per oral route. They can undergo special training and can be designated as AMS (antimicrobial stewardship) Nurse. The nursing supervisor or in charge can act as link of communication between AMS team and administration also. It all depends upon administration how much credentials and privileges are given to senior nursing staff. They are best candidates for OT implementation of surgical prophylaxis and also for improvising and supervising same.
This is era of documentation. This is era of evidence based practice so probably all efforts needs documentation. There should be Standard operating procedures