Antimicrobial stewardship

177 Pages·2016·3.1 MB·English

by  Gilchrist

Antimicrobial stewardship

Antimicrobial
stewardship
Edited by
Matthew Laundy
Mark Gilchrist
Laura Whitney
1
1
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To our children: Amelia, Freya, Jacob, and Sophie.
May our actions now make a safer future for you.

The fault, dear Brutus, is not in our stars.
But in ourselves, that we are underlings.
Julius Caesar (Act I, Sc. II)
William Shakespeare

Preface
The twentieth century has been described as the golden age of antimicrobials. With the introduc-
tion of antimicrobials previously deadly infectious diseases were relegated to history. Now in the
second decade of the twenty- first century it has become increasingly obvious to even the most
disinterested member of the public, healthcare professional, or politician that there is a problem
with antimicrobial- resistant organisms and untreatable infections. This problem of antimicrobial
resistance has been raised as a worldwide concern alongside global warming, and the popular
press regularly raises the spectre of a ‘return to the dark ages’.
While resistance is an inevitable evolutionary process, two factors have accelerated the devel-
opment of untreatable infections. Firstly the pharmaceutical industry had lost interest in anti-
microbial development, primarily for financial reasons, and so there are fewer new classes of
antimicrobials in the pipeline as a consequence. The second is the overuse and abuse of antimi-
crobials by the medical profession, the public, and the agricultural industry.
The concept of antimicrobial stewardship has been developing within the infection community
over the last 15 years. The aim of antimicrobial stewardship is to restrict antimicrobial use in order
to reduce the development of resistance, avoid the side effects associated with antimicrobial use,
and optimize clinical outcomes. In its simplest form it’s about saving what antimicrobials we have.
This is a rapidly developing field. The number of academic papers on antimicrobial stewardship
has increased dramatically in the past 5 years, from 43 in 2008 to 429 in 2015.
Our aim is to produce a very practical approach to antimicrobial stewardship. It’s very much a
‘how to’ guide supported by a review of the available evidence.
The book is divided into three sections.
Section 1: Setting the scene and starting up: in this section we look at the problem of antimicro-
bial resistance, problems in the antimicrobial supply line, and initiatives to improve the situation.
We examine the psychological, social, cultural, and organizational factors in antimicrobial use
and prescribing. We look at the principles and goals of antimicrobial stewardship. Finally we look
at how to establish an antimicrobial stewardship programme.
Section 2: Components of an antimicrobial stewardship programme: in this section we examine
the identified components of an antimicrobial stewardship programme— prospective audit and
feedback, antimicrobial policies and formularies, antimicrobial restriction, intravenous to oral
switch, measuring antimicrobial consumption, and measuring and feeding back stewardship; we
conclude with a look at information technology in antimicrobial stewardship.
Section 3: Special areas in antimicrobial stewardship: in this section we explore specific areas
of antimicrobial stewardship including antimicrobial pharmacokinetics and dynamics, intensive
care units, paediatrics, surgical prophylaxis, near- patient testing, and infection biomarkers. We
will also look at antimicrobial stewardship in the community and long- term care facilities, where
arguably there is most to be done. We conclude the book by looking at antimicrobial stewardship
in resource- poor settings and the unique challenges facing low- and middle- income countries.
Infection control is a vital component in the control of the spread of resistant organisms. We
will touch on aspects of infection control, but there are many textbooks that can cover this subject
in far more detail that we are able to here. We will not cover the exact mechanisms of antimicro-
bial resistance as this field is rapidly developing and the book would soon be out of date, nor is this
a pharmacology book on antimicrobials. The issue of the widespread use of antimicrobials in the