Antimicrobial stewardship generally refers to hospital-based programs that attempt to improve the use of antimicrobial agents. These programs have arisen in large part because of the growing problem of antimicrobial resistance, and the sad (but entirely logical) recognition that antibiotic prescription guidelines are insufficient for improving antibiotic use and often poorly implemented. Appropriate antibiotic prescription is a difficult (and poorly appreciated) skill, balancing the clinical needs of the patient against the immediate risks of adverse effects, the subsequent risks of infection/colonization with drug-resistant bacteria, and the future ecological issues of antimicrobial resistance in that particular institution. The “hit hard and hit fast” strategy of antibiotic prescription, especially in the ICU, is critical but often abused. Practitioners often lack the knowledge (or courage) to “de-escalate” or stop antibiotics afterwards.
CDC (Atlanta) has a nice page summarizing the core elements of antimicrobial stewardship:
- Leadership commitment.
- Drug expertise
- Reporting, and
The more comprehensive IDSA/SHEA guidelines can be found here. And colleagues in Singapore have also published guidelines for antimicrobial stewardship and practice locally. Currently, the larger public sector hospitals in Singapore all have comprehensive antimicrobial stewardship programs with good outcomes in terms of improving appropriate prescription and cost control. The far-reaching goal of reducing antimicrobial resistance rates is much harder to achieve, but antimicrobial stewardship is one key facet of the overall strategy required for this.