Three recent, excellent reviews have also defined pressing research need within the field. Author contributions: FR conceived, organised and wrote the review. Conflict of interest statement: The author declare that there is no conflict of interest. National Center for Biotechnology Information , U.
Ther Adv Infect Dis. Published online Jun Fredrik Resman. Author information Article notes Copyright and License information Disclaimer.
Email: es. Received Mar 13; Accepted May This article has been cited by other articles in PMC. Keywords: antibiotics, antimicrobial stewardship, implementation science.
Background and context Antimicrobial resistance provides a formidable challenge to healthcare as we know it. Open in a separate window. Figure 1. A five-step guide to designing an antimicrobial stewardship intervention Step 1: Prior to start — define specific aims of the ASP Regardless of context, all ASPs should strive to have clearly defined aims. Defining antimicrobial stewardship and responsible use of antibiotics Antimicrobial stewardship is a term that is used liberally in a variety of contexts.
What is the overarching objective of antimicrobial stewardship? What are reasonable aims for stewardship programs? Step 1 — Tips on defining aims of the planned intervention. ASP, antimicrobial stewardship program. Summary Pre-defined aims should be a part of antimicrobial stewardship design. Step 2: Prior to start — choose metrics, assess current performance and barriers to rational and responsible antimicrobial use Prior to a successful intervention, an assessment of current performance and an analysis of the most prominent barriers to reaching the proposed aim of the intervention the unmet need is essential.
By what metrics should current performance be assessed? Table 2. Step 2 — Potential metrics and their assessment. Step 2 Choose metrics, assess current performance and assess barriers to rational use Metrics to choose from Assessment Patient outcome metrics; All-cause mortality, infection-related re-occurrence or re-admission, number of unintended effects etc.
Should be a part of an analysis. The more causally related to the intervention, the better patient outcome metric Quantitative antibiotic use metrics; DDD, DOT or number of prescriptions per capita outpatient care Choose metric based on: What can be reliably measured, and What will allow benchmarking Adjust for case-mix or use SAAR Strict process metrics; How is protocol followed, who attends rounds, how many changes to treatment courses are made, etc.
Measures the reach, fidelity and usefulness of an antimicrobial stewardship intervention Evaluates implementation quality and perceived usefulness Qualitative metrics; Appropriateness of use, compliance to clinical guidelines, quality indicators Appealing in theory, but often challenging in practice Quality indicators may be useful Microbial outcome measures; Incidence of Clostridioides difficile infections, prevalence and infections caused by antibiotic-resistant organisms Effect affected by many factors outside of ASPs Often slow changes over time Cost measures; Costs directly related to antibiotics, costs related to length of stay in hospital, costs related to other outcomes.
Often presented, Important in practice, but not directly related to the general objectives of ASPs. Table 3. Step 3 — Different intervention strategies and their assessment. Step 3 Decide on a general intervention strategy Intervention type Assessment Restriction intervention Supported by scientific evidence May have low level of acceptance Flexible, but demanding Can be adjusted to barriers Enablement intervention Supported by scientific evidence Higher degree of acceptance Flexible, but demanding and sustained programs may be challenging Can be adjusted to barriers Education and guidelines Not supported by evidence as sole measure, Complementary to restriction or intervention Can be adjusted to barriers Antibiotic cycling Not supported by scientific evidence Not very flexible Not very demanding Behavourial change interventions Promising Not enough studied in the context of antimicrobial stewardship Mixed strategy Appealing due to flexibility Better adjusted to actual barrier analysis Less generalizability.
Benchmarking current performance We suggest assessing current performance prior to the start of any antimicrobial stewardship intervention. Barriers to rational and responsible antimicrobial use Why are antimicrobials not always given responsibly and rationally? How are barriers best assessed? Summary Prior to initiating an ASP, the assessment of current performance as well as an assessment of barriers and facilitators to rational use of antibiotics, is recommended.
Step 3: Prior to start — based on aims, current performance, barrier analysis and scientific evidence, decide on an intervention strategy Whichever aims are stated, and whatever determinants are defined as the greatest barriers to reaching that aim, a specific intervention should always be designed with respect to the scientific evidence. Evidence-based stewardship design — a myth of fingerprints? Choosing a strategy based on current performance and barrier assessments It is thus clear from scientific evidence that certain types of interventions, mainly restriction and enablement interventions, have higher potential to change prescription behaviour.
Summary Several different types of antimicrobial stewardship interventions may have a positive effect on outcomes, but the available scientific evidence favours programs based on either restriction or enablement interventions. Step 4: Start — Include core components, tailor to your particular setting and assure proper implementation Following the definition of aims, the assessment of barriers to rational antimicrobial use and deciding on an antimicrobial stewardship intervention type, a practical stewardship program needs to be designed.
Table 4. Step 4 — Core component and respective reflections. Step 4 Core components of antimicrobial stewardship programs Core component Reflection Senior management commitment Essential for general support and resource allocation.
Accountability and leadership Essential for external accountability Define and document a team, respective responsibilities and plans for reporting Make sure the team and the proposed intervention is accepted and has mandate in the intervention target group Subject matter expertise A necessity in any expert-based intervention Action plans for antimicrobial use improvement Has been reflected on in steps 2 and 3 Education and practical training Of the stewardship team as well as of the target group of the intervention Often overlooked Monitoring use and disease epidemiology A necessary part of any program, reflected upon in step 2 Report, evaluate and give feedback Will be reflected on in step 5.
Adjusting to local prerequisites and settings The stewardship team In international literature, the stewardship team generally consists of infectious disease physicians, pharmacists, microbiologists and, possibly, administrators. Populations and settings other than adult hospital care Most ASPs focus on adults treated in hospital care. Considerations in low- and middle-income settings The health-care system organisation, the availability of diagnostic testing and antibiotics in the AWaRe access category, public awareness and prescribing practices differs between high-income countries and low- and middle-income countries LMIC.
Focusing on specific disease syndromes In response to analysis of determinants of antimicrobial use, it may be reasonable and cost-effective to focus effort on specific disease syndromes, or even specific antibiotics. Evidence-based implementation techniques of ASPs In reality, the techniques of a healthcare intervention and the implementation of that intervention overlap substantially and are sometimes confused.
Summary Regardless of the prior steps, sustainable success of antimicrobial stewardship requires the establishment of core elements such as commitment from leadership, proper resources, staff expertise and accountability. Step 5: After start — pilot, evaluate and either re-assess or integrate into clinical care Three essential, but often neglected, parts of antimicrobial stewardship design are testing, evaluating and planning for sustainability or change.
What is the state of quality of research of antimicrobial stewardship interventions? Practical testing, evaluation and reporting of stewardship interventions A reasonable start to any complex intervention in a new setting is to perform a pilot intervention.
Table 5. Step 5 — A flowchart for initial evaluation. Do we address the identified barriers? Have we tailored the intervention properly? How can we make effects sustainable? Evaluating costs and benefits The issue of cost-effectiveness is essential in order to provide a rational basis for prioritising between different efforts to counter antimicrobial resistance. Summary A necessary part of any intervention program is to have a plan for evaluation using robust evaluation techniques.
Conclusion and future aspects A successful antimicrobial stewardship intervention needs to be carefully planned and implemented in order to maximise chances of success. Footnotes Contributed by Author contributions: FR conceived, organised and wrote the review. References 1. An update from the infectious diseases society of America. Clin Infect Dis.
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The primary outcome associated with these interventions has been the associated cost savings; however, few published investigations have taken into account the overall cost of the intervention. Over the past 5 years, there has been an increased focus upon interventions intended to decrease bacterial resistance or reduce superinfection, including infections associated with Clostridium difficile colitis.
Few programs have been associated with a reduction in antimicrobial drug adverse events.
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