Infect. Dis. Rep., Volume 9, Issue 1 (March 2017) – 9 articles

Antimicrobial stewardship is widely accepted as an efficient strategy to combat the growing threat of antimicrobial resistance. Education is one of the cornerstones of successful antimicrobial stewardship programs. There is also general agreement that antimicrobial stewardship is a team effort that must involve the whole continuum of healthcare workers. Providing adequate education for all different professionals although challenging is deemed crucial to achieve good results. This paper reviews the different strategies available to educate the multiple healthcare workers, discusses how education can improve antimicrobial stewardship programs and outlines some of the challenges faced and research gaps that need to be addressed in order to improve education in this field. Full article

Antimicrobial resistance is a worldwide threat and a problem with large clinical and economic impact. Antimicrobial Stewardship Programs are a solution to curb resistance development. A problem of resistance is a separation of actions and consequences, financial and clinical. Such a separation makes it difficult to create support among stakeholders leading to a lack of sense of responsibility. To counteract the resistance development it is important to perform diagnostics and know how to interpret the results. One should see diagnostics, therapy and resistance as one single process. Within this process all involved stakeholders need to work together on a more institutional level. We suggest therefore a solution: combining diagnostics and therapy into one single financial product. Such a product should act as an incentive to perform correct diagnostics. It also makes it easier to cover the costs of an antimicrobial stewardship program, which is often overlooked. Finally, such a product involves all stakeholders in the process and does not lay the costs at one stakeholder and the benefits somewhere else, solving the misbalance that is present nowadays. Full article

This review sets out to evaluate the current evidence on the impact of inappropriate therapy on bloodstream infections (BSI) and associated mortality. Based on the premise that better prescribing practices should result in better patient outcomes, BSI mortality may be a useful metric to evaluate antimicrobial stewardship (AMS) interventions. A systematic search was performed in key medical databases to identify papers published in English between 2005 and 2015 that examined the association between inappropriate prescribing and BSI mortality in adult patients. Only studies that included BSIs caused by ESKAPE (Enterococcus faecium/faecalis, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa and Enterobacter species) organisms were included. Study quality was assessed using the GRADE criteria and results combined using a narrative synthesis. We included 46 studies. Inappropriate prescribing was associated with an overall increase in mortality in BSI. In BSI caused by resistant gram positive organisms, such as methicillin resistant S. aureus, inappropriate therapy resulted in up to a 3-fold increase in mortality. In BSI caused by gram negative (GN) resistant organisms a much greater impact ranging from 3 to 25 fold increase in the risk of mortality was observed. While the overall quality of the studies is limited by design and the variation in the definition of appropriate prescribing, there appears to be some evidence to suggest that inappropriate prescribing leads to increased mortality in patients due to GN BSI. The highest impact of inappropriate prescribing was seen in patients with GN BSI, which may be a useful metric to monitor the impact of AMS interventions. Full article

Early availability of information on bacterial pathogens and their antimicrobial susceptibility is of key importance for the management of infectious diseases patients. Currently, using traditional approaches, it usually takes at least 48 hours for identification and susceptibility testing of bacterial pathogens. Therefore, the slowness of diagnostic procedures drives prolongation of empiric, potentially inappropriate, antibacterial therapies. Over the last couple of years, the improvement of available techniques (e.g. for susceptibility testing, DNA amplification assays), and introduction of novel technologies (e.g. MALDI-TOF) has fundamentally changed approaches towards pathogen identification and characterization. Importantly, these techniques offer increased diagnostic resolution while at the same time shorten the time-to-result, and are thus of obvious importance for antimicrobial stewardship. In this review, we will discuss recent advances in medical microbiology with special emphasis on the impact of novel techniques on antimicrobial stewardship programs. Full article

There is now global recognition that antibiotic resistance is an emerging public health threat. Policy initiatives are underway to provide concrete suggestions for overcoming important obstacles in the fight against antibiotic resistance, like the alarming current paucity of antibacterial innovation. New economic models are needed as incentives for the discovery and development of novel antibacterial therapies especially for infections with too few patients today to justify private sector research and development (R&D) investments. These economic models should focus on rewarding the innovation, not the consumption of the antibiotic since sustainable use policies will reduce selection pressure and slow the emergence of resistance. To effectively stimulate greater innovation, the size of the reward must be commensurate with revenues from other therapeutic areas, estimated at about a billion dollar total pay-out. Otherwise R&D investment will continue to move away from antibiotics to areas where returns are more attractive. A potential sizeable public investment, if implemented, must be protected to ensure that the resulting antibiotics have a lengthy and positive impact on human health. Therefore, public investments in innovation should be bound to sustainable use policies, i.e., policies targeted at a range of actors to ensure the preservation of the novel antibiotics. These policies would be targeted not only at the innovating pharmaceutical companies in exchange for the reward payments, but also at governments in countries which receive the novel antibiotics at reasonable prices due to the reward payment. This article provides some suggestions of sustainable use policies in order to initiate the discussions. These are built on planned policies in the US, EU, WHO and have been expanded to address One Health and environmental aspects to form One World approaches. While further discussion and analyses are needed, it is likely that strong sustainable use policies will help to protect the sizeable public health investments. Full article

The rise of antimicrobial resistance (AMR) is a severe global health problem. Tackling this problem requires the prudent prescribing of antimicrobials. This is promoted through Antimicrobial Stewardship Programs (ASPs). In this position paper we describe i) how a socio-technical multidisciplinary approach (based on the CeHRes Roadmap) can be applied in the development and implementation of Antimicrobial Stewardship technologies and ii) how this approach can be of value to support Antimicrobial Stewardship in practice. The CeHRes Roadmap entails five different phases to explore and test how an eHealth technology can be tailored to the target group and successfully implemented in practice: i) contextual inquiry, ii) value specification, iii) design, iv) operationalization, v) evaluation. In this position paper we describe the lessons learned from research and practice to guide future developments of technology based ASP interventions. Since AMR is a huge wicked problem on a global level, it requires innovative methods and models to empower general public and professionals to be proactive rather than reactive in a digitalized world. We highlight how to combat the dangerous rise of antimicrobial resistance in the future. Full article

Many quality indicators for appropriate antibiotic use have been developed. We aimed to make a systematic inventory, including the development methodology and validation procedures, of currently available quality indicators (QIs) for appropriate antibiotic use in hospitalized adult patients. We performed a literature search in the Pubmed interface. From the included articles we abstracted i) the indicators developed ii) the type of infection the QIs applied to iii) study design used for the development of the QIs iv) relation of the QIs to outcome measures v) whether the QIs were validated and vi) the characteristics of the validation cohort. Fourteen studies were included, in which 200 QIs were developed. The most frequently mentioned indicators concerned empirical antibiotic therapy according to the guideline (71% of studies), followed by switch from IV to oral therapy (64% of studies), followed by drawing at least two sets of blood cultures and change to pathogen-directed therapy based on culture results (57% of studies). Most QIs were specifically developed for lower respiratory tract infection, urinary tract infection or sepsis. A RAND-modified Delphi procedure was used in the majority of studies (57%). Six studies took outcome measures into consideration during the procedure. Five out of fourteen studies (36%) tested the clinimetric properties of the QIs and 65% of the tested QIs were considered valid. Many studies report the development of quality indicators for appropriate antibiotic use in hospitalized adult patients. However, only a small number of studies validated the developed QIs. Future validation of QIs is needed if we want to implement them in daily practice. Full article

Antimicrobial stewardship is recognized as a key component to stop the current European spread of antimicrobial resistance. It has also become evident that antimicrobial resistance is a problem that cannot be tackled by single institutions or physicians. Prevention of antimicrobial resistance needs rigorous actions at ward level, institution level, national level and at supra-national levels. Countries can learn from each other and possibly transplant best practices across borders to prevent antimicrobial resistance. The aim of this study is to highlight some of the success stories of proven cost-effective interventions, and to describe the actions that have been taken, the outcomes that have been found, and the difficulties that have been met. In some cases we came across substantial scope for real-life cost savings. Although the best approach to effectively hinder the spread of antimicrobial resistance remains unclear and may vary significantly among settings, several EU-wide examples demonstrate that cost-effective antimicrobial stewardship is possible. Such examples can encourage others to implement (the most cost-effective) elements in their system. Full article