1240
measurable clinical outcomes and feasible interventions that achieve short- and long-term AMS program goals. After imple- menting these interventions, the team should begin monitoring AMS program processes and outcomes. Regular team meetings must be scheduled to review AMS program activities and AMR data and to modify the program. One strategy is to incorporate serial plan-do-study-act (PDSA) cycles to evaluate the effects of AMS interventions and implement further changes as required to improve processes and achieve outcomes.36
AMS program interventions
A recent systematic review and meta-analysis of AMS programs in hospitals in Asia showed that AMS implementation was associated with reduced carbapenem and overall antimicrobial consumption, reduced antibiotic expenditure, and trends toward
Anucha Apisarnthanarak et al
reductions in the incidence of MDR pathogens.17 Many programs implemented bundled interventions, making it difficult to deter- mine which individual interventions contributed to the success of the AMS program.17 However, on the basis of these and other reports,8,16,18 we recommend a range of AMS strategies (Table 5), any number of which can be selected to form AMS programs.
Recommended physician-driven interventions
Implementation of local guidelines for surgical prophylaxis and empiric antibiotic therapy of common infection syndromes (strong recommendation, low-quality evidence). As has occurred in China and Vietnam, Asian countries should work toward establishing their own national or regional guidelines for antibiotic ther- apy.13,37 Facility-specific guidelines for infection syndromes commonly treated in hospitals can be adapted from pre-existing national, regional, or international guidelines to suit the types of infection commonly seen at the local facility.19,38,39
Use of monotherapy instead of combination antibiotics (strong recommendation, high-quality evidence). For many common infections, monotherapy is often one of the most practical, straightforward approaches to reducing antibiotic consump- tion.40–43 Evidence indicates that routine use of combination therapy is not superior to monotherapy in terms of outcome for sepsis, endocarditis, neutropenia, and gram-negative infections, or for preventing AMR, and that more toxicity is seen with com- bination therapy.44–49 Where appropriate, guidelines should advocate monotherapy as a first-line option, especially for those who are not critically ill.
Fig. 1. An ideal hospital antimicrobial stewardship (AMS) program team structure.
Table 4. AMS Core Team Member Roles and Responsibilities Team Member
Role
Infectious disease specialista
Clinical pharmacist Team leader
Use of antibiotic diversity (eg, multiple agents and classes) (strong recommendation, low-quality evidence). A quantitative relation- ship between the volume of antibiotics consumed and the development of AMR has been demonstrated; resistance to
Responsibilities
∙ Development of clinical pathways and guidelines ∙ Formulary choices ∙ Reviewing antibiotic use data ∙ Education
Coleader
∙ Assist team leader (guideline development and formulary choices) ∙ Guiding optimal antibiotic dosing ∙ Guiding switching from IV to oral ∙ Identifying de-escalation opportunities ∙ Compiling antibiotic use data ∙ Education
Clinical microbiologist Diagnostic support
∙ Guiding appropriate specimen collection, cultures and tests ∙ Ensuring accurate pathogen identification and susceptibility testing ∙ Ensuring timely reporting and clear interpretation of patient-specific culture results (including probable contamination or colonization)
∙ Regular provision of antibiograms ∙ Keeping abreast of new developments in the field of diagnostics
Infection control expert
Information technology expert
Infection control support ∙ Monitoring and reporting outbreaks of MDR bacterial infections ∙ Education
Information technology support
∙ Developing and maintaining computerized AMS systems, including – Data collection and analysis – Prompts for action (ie, stops on antibiotic prescriptions requiring review; prescription review reminders)
– Clinical decision support systems for antibiotic use
Note. AMS, antimicrobial stewardship; IV, intravenous; MDR, multidrug resistant. aIf no ID specialists are available, another physician or pharmacist with an interest in infectious diseases can assume responsibility for this role.
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