Antimicrobial Stewardship

Introduction

Antimicrobials are used to prevent and treat infectious diseases in humans, animals, and plants. These include:

  • Antibiotics
  • Antivirals
  • Antifungals
  • Antiparasitics

Over time, coupled with frequent use (due to misuse and overuse of antimicrobials), microbials can evolve and become resistant to existing antimicrobials.

  • As a result, these medications become ineffective, and infections can persist in the body.

Moreover, the development of truly novel antibiotics has significantly slowed in recent decades, leading to a critical shortage of effective treatments for severe infections.

  • Infection with resistant microorganisms has severe consequences across all areas of health, including prolonged illnesses, extended hospital stays, increased healthcare costs and mortality, and compromised protection for patients undergoing surgeries and other procedures.

How Antimicrobial Resistance Spread



The Importance of Patient Education

Misperceptions about the natural progression of infections have fostered unwarranted concern that antibiotics are always necessary.

  • Many patients and parents expect respiratory tract infections, such as sore throats and coughs, to resolve faster than is typical.
  • Educating patients about the expected duration of their specific infection helps establish realistic expectations for symptom resolution.

Parents naturally worry more about their child's infection than their own.

  • While some patients initially question a viral illness diagnosis or a non-antibiotic treatment recommendation, they generally respond positively to careful listening, thorough examinations, and clear explanations for why antibiotics are not needed, with alternatives recommended for relieving symptoms.
  • The 'When Should I Worry?' booklet is a helpful tool for these conversations.



The 4 Moments of Antibiotic Decision Making

Initiation of antibiotic therapy

  • Does my patient have an infection that requires antibiotics?

Decision to start antibiotics

  • Have I ordered appropriate cultures before starting antibiotics?
  • What empiric therapy should I initiate?

Every day of antibiotic therapy

  • Can I stop antibiotics?
  • Can I narrow therapy?
  • Can I change from IV to oral therapy?

When infectious process is clear and patient responds to therapy

  • What duration of antibiotic therapy is needed for my patient's diagnosis?



AWaRe Classification

The AWaRe classification of antibiotics was developed by the World Health Organization (WHO) to assist in antibiotic stewardship efforts at local, national and global levels.

  • The AWaRe classification categorizes antibiotics into 3 groups based on their impacts on antimicrobial resistance and the important of their appropriate use.

The three AWaRe Groups are

  • Access antibiotics have a narrow spectrum of activity, lower cost, a good safety profile and generally low resistance potential. They are often recommended as empiric first or second-choice treatment options for common infections.
  • Watch antibiotics are broader-spectrum antibiotics, generally with higher costs and are recommended only as first-choice options for patients with more severe clinical presentations or for infections where the causative pathogens are more likely to be resistant to Access antibiotics, such as upper urinary tract infections (UTIs).
  • Reserve antibiotics are last-choice antibiotics used to treat multidrug-resistant infections.



Summary

Antimicrobial stewardship has been defined as the optimal selection, dosage, and duration of antimicrobial treatment that results in the best clinical outcome for the treatment or prevention of infection, with minimal toxicity to the patient and minimal impact on subsequent resistance.



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