The elements that an Antimicrobial stewardship program must include

Take a look into the elements of Antimicrobial Stewardship

- a multidisciplinary task requiring coordinated interventions designed to improve and measure the use of antimicrobials.

Elements of antimicrobial stewardship

Bacterial resistance is driven by the continued use of antimicrobials and the threat of resistance can only be effectively mitigated either by the discovery of new antimicrobials or by a reduction in the use of antimicrobials, in particular broad-spectrum antimicrobials. The already small and dwindling pipeline of antimicrobial drug candidates makes it unlikely that the rescue will come from newly discovered drugs. The only currently available course of action is to find ways of using the existing antimicrobials more prudently, an activity referred to as Antimicrobial Stewardship.
Implementing antimicrobial stewardship is a multidisciplinary task requiring coordinated interventions designed to improve and measure the use of antimicrobials by promoting the selection of the optimal antimicrobial drug regimen, dose, duration of therapy, and route of administration.
The goals of antimicrobial stewardships are many, e.g. to achieve optimal clinical outcomes related to antimicrobial use, minimize toxicity and other adverse events, reduce the costs of health care for infections, and limit the selection for antimicrobial resistant strains.

Hospital based programs dedicated to improving antimicrobial use, commonly referred to as “Antimicrobial Stewardship Programs” can both optimize the treatment of infections and reduce adverse events associated with antimicrobial use. TREAT Steward is the first software program that handles and combines every aspects of Antimicrobial Stewardship and links everything together in one revolutionary tool.

Click on the elements below to learn more about the elements of antimicrobial stewardship.

Stakeholders
– Who is interested in antimicrobial stewardship? As shown below, in principle, everyone should be interested in antimicrobial stewardship.

Treat Systems Stakeholder patient

Patient

Minimize risk for infection
Reduce unnecessary treatment
Reduce adverse antimicrobial effects
Reduce use of broad-spectrum antimicrobials
Minimize treatment duration
Use the least toxic drug and delivery form
Minimize risk for being infection with resistant microbes

Treat Systems Stakeholder society

Society

Reduce drug costs
Decrease bed days
Decrease mortality
Reduce antimicrobial resistance
Save money

Treat systems Stakeholder Clinicians

Clinicians

Show all infection relevant data in one system
Education
Intelligent guideline
De-escalation and parenteral to oral support
Surveillance and real time alerts
Hepatic and renal monitoring
Dosage and duration optimization
Allergies and drug-drug interactions
Isolation support
Rapid diagnostics

Treat Systems Stakeholder Disease specialists

Disease specialists

Increase guideline compliance
Calibrated to local pathology environment
A-team review tool and follow-up opportunity
Easy implementation and distribution of new antimicrobial guidelines
Research facilities
Easy to adjust to local workflow and terminology
Antimicrobial treatment review and refinement

Treat Systems Stakeholder Hospital

Hospital

Reporting and statistics service for ecological cost, cost of antimicrobials, bed-days, mortality, coverage, bacterial resistance
Saves money AND improves outcome
Minimizes staff overhead time

Integration
– The key to the success of your antimicrobial stewardship program

Antimicrobial stewardship programs should integrate seamlessly into existing hospital IT systems and elegantly show all infection relevant information for clinicians, specialists, and management. The program must be able to handle different types of data complexity, typically from many different systems and electronic health record providers:


  • Information about patient demographics like name, age, gender, department and admission dates
  • Vital signs obtained by the nurses like temperature, heart rate, respiratory rate and blood pressure
  • Information about patient background and infection risk factors like catheters, functional capacity and pacemakers
  • Clinical chemistry laboratory test results like hematology, biochemistry values and blood gases
  • Test results of microbiological samples like PCR, microscopy, blood and local cultures
  • Information about previous and current medicine and allergies
  • Integration to existing workflow and activation of the program from the hospital electronic health record
  • Single log on and integration to hospital safety procedures
  • Export infection note to electronic health record system

Read more about the integration of TREAT Steward here.


Integration TREAT Steward

A-team
– Give the control to those with the highest competences

Implementation of an antimicrobial stewardship program requires a multidisciplinary approach with involvement of clinical pharmacists, infectious diseases and microbiological specialists as its core team members.
Antimicrobial stewardship programs should provide a review tool for a special antimicrobial team of these members – “The A-Team”.
With this tool, it should be possible for the A-team to audit and give direct feedback to prescribers of antimicrobials. The review should include a range of point-of-care stewardship interventions useful to provide direct and timely feedback to the prescriber at the time of prescription or laboratory diagnosis, and provide an opportunity to educate clinical staff on appropriate prescribing.

Point-of-care interventions can include:


  • Appropriate use of guidance and follow up on guideline compliance
  • Indication for antimicrobial
  • Choice of drug
  • Route of administration (IV vs. PO)
  • Frequency and timeliness of treatment
  • Site of infection
  • Likelihood of on-going infection or not
  • Use of further investigation
  • Interpretation of microbiology
  • Help on de-escalation or stopping therapy
  • Duration of therapy

The program must ensure that data is easily available for audit process to define areas for improvement and provide structured feedback.


Read more about the A-team facilities in TREAT Steward here.


A-team of TREAT Steward

Patient records
– Remember to ask yourself and the patient all the right questions

At present, electronic patient record systems in Western hospitals store a tremendous amount of information. Unfortunately, it is mainly stored as free-text with the lack of any utility for purposes other than accessing such information. Furthermore, different clinicians report and write patient records in different ways, which may cause the record to be difficult to read and understand. It might even miss important information that ultimately could have fatal consequences.

Ideally, an antimicrobial stewardship program should guarantee that every infectious patient is examined and treated with equal quality. This must be done by ensuring that all risk factors, relevant information about the patient background, and clinical symptoms and findings are captured consistently.

The benefits of capturing coded clinical information is that it can be linked to knowledge in the domain of evidence-based medicine and used to provide tailored recommendations at the point of care. Such integrated clinical decision support should then be able to help close the large, well-documented gap between best evidence and actual clinical practice.

Antimicrobial stewardship programs should provide quality assurance that helps clinicians to obtain patient records in a fast, structured and automatic way – asking the right questions at the right time.


Read more about how TREAT Steward handles patient records here.


Patient records TREAT Steward

Education
– Follow the outcome of the patients I have treated

One of the problems with the treatment with antimicrobials, especially in the emergency room, is that it is given empirically before microbiology results are available. The next day the patient might have moved to another department or been sent home and typically, clinicians do not see the clinical effect of their choice of drug with respect to coverage.
Ongoing education and sharing of knowledge is one of the keys to prevent the spread of infection. Antimicrobial stewardship programs should therefore provide the opportunity for infection specialists to share their knowledge with less experienced clinicians on a case-by-case basis. More importantly, it should give each clinician the opportunity to follow the clinical outcome of the exact patients he or she has treated.


Read more about the educational and statistical features of TREAT Steward here.


Education TREAT Steward

Statistics
– Structured data is the key to knowledge

One of the true benefits of having coded clinical information in an antimicrobial stewardship program is that it can be linked to the vast knowledge within the domain of evidence-based medicine and be given as an input to decision support systems. However, what is even more important is that it can be used for statistical purposes.
An antimicrobial stewardship program must be able to handle and combine different types of data complexity in one database. Information about patient background, demography, clinical findings, infection values and vital signs must be combined with identified microbiology. In this way, an antimicrobial stewardship program must deliver value by allowing access to all infection relevant information about clinical performance, antimicrobial usage and guideline compliance both for management and research purposes.


Read more about the management report of TREAT Steward here.


Statistics TREAT Steward

Clinical decision support
– A helping hand to answer your questions

One of the key elements in an antimicrobial stewardship is the ability to use health care information technology and clinical decision support systems. These systems offer a great potential to improve clinical knowledge management and identify situations of antimicrobial misuse since they have the capability to address patient-specific problems while accounting for institutional and individual variances. In principle, the decision support system should answer the following questions:


  • Is there a bacterial infection?
  • How severe is the infection?
  • What is the most likely site of infection?
  • Which pathogens are responsible?
  • What are the benefits and costs of potential antimicrobial regimes?

Clinical decision support systems that target infectious diseases and antimicrobial drug use as their focus must take into account many different aspects to answer these questions for the infectious disease patient. Some of these components are technically trivial, whereas others require sophisticated architectures and design:


  • Local pathogen distribution and prevalence
  • Antimicrobial in vitro susceptibilities
  • In vivo modification of susceptibilities due to blood-brain barrier etc.
  • Intrinsic- and cross-resistance and cross-susceptibility
  • Local available treatment list
  • Bioavailability due to degree of sepsis
  • Mortality rates of different infectios diseases
  • Effect of previous treatment
  • Antimicrobial allergies
  • Local hospital antimicrobial policies
  • Effect of individual risk factors, symptoms and findings on diagnosis and pathogen distribution
  • Estimation of severity of infection and probability of bacteremia based on vital signs, infection numbers from clinical chemistry etc.
  • Microbiological contamination rates
  • Side effects and purchasing cost of different antimicrobials
  • Ecological cost of resistance development of individual treatments

Even though clinical decision support systems have great potential, it is important to remember that they generate suggestions – clinicians make decisions.


Read more about the clinical decision support within TREAT Steward here.


Clinical decision support TREAT Steward

Treatment quality
– Main clinical goal is to improve patient outcome in the long run

Ultimately, antimicrobial stewardship programs should help clinicians improve the quality of patient care and improve patient safety through increased infection cure rates, reduced treatment failures, and increased frequency of correct prescribing for therapy and prophylaxis. Therefore, one of the important focus areas of antimicrobial stewardship is to provide continuous prospective monitoring the appropriateness of antimicrobial prescribing. Measurements of the quality of prescribing can provide assurance that the most effective therapy is being given, and that the risk of poor outcomes, including antimicrobial-related adverse events, is being reduced.

Antimicrobial stewardship programs should be able to provide access to measures of treatment quality outcomes such as the use of broad-spectrum antimicrobials and empirical coverage of microbiologically documented infections. Other clinical outcome measures such as mortality, readmission rates and length of hospital stay may be too indirectly related to appropriate antimicrobial prescribing to be an accurate reflection of the performance of antimicrobial stewardship programs. However, a reduction in bacterial resistance and a decrease in clinically documented infections are proposed as key metrics to consider when evaluating the effect of antimicrobial stewardship programs.


Read more about the clinical performance of TREAT Steward here.


Treatment quality TREAT Steward