By Peter Zhang, Corlissa Chan, and Certina Ho
With infectious diseases in the public spotlight, there is a growing recognition for the need of antimicrobial stewardship within and beyond the hospital setting.
Throughout this pandemic, COVID-19 has taught us of how vulnerable we are without viable treatments against deadly microbes. Without effective antimicrobial stewardship, this may, one day, be the eventuality of other types of infectious diseases.
Antimicrobial stewardship is the practice of ensuring that patients receive optimal antimicrobial therapy. While stewardship is an important aspect of practice for any clinician, antimicrobial stewardship programs provide formal structure to this practice.
In addition to reducing antimicrobial resistance rates, stewardship programs protect patients from the adverse effects of unnecessary antimicrobial exposure. The growing role of stewardship in routine clinical care brings together interdisciplinary teams of healthcare professionals in the fight against the rise of antimicrobial resistance.
In recent years, the growing use of broad-spectrum antibiotics has resulted in increasingly resistant strains of bacteria. While all antibiotics can exert pressures that select for resistance, broad-spectrum antibiotics can exert this effect on bacteria beyond the ones responsible for the disease in question, leading to unnecessary increases in antibiotic resistance. As a result, infectious disease can become dangerously difficult to treat, as viable treatment options dwindle to fewer and fewer antimicrobial agents.
Research in this area has repeatedly shown that antimicrobial stewardship programs can reduce the use of broad-spectrum antibiotics. But what do antimicrobial stewardship teams really do? And why are these programs important to the point of being required for hospital accreditation?
The Antimicrobial Stewardship Program
On the stewardship team, pharmacists will review antimicrobial therapy to determine whether its use is appropriate on an ongoing basis. Appropriateness can take many forms. For example, a broad-spectrum antibiotic may be inappropriate when a specific pathogen has already been identified. On the other hand, if the antibiotic therapy was too narrow, and did not cover the likely organisms involved, the stewardship team would intervene as well. This strategy ensures optimal patient care while reducing the unnecessary usage of antimicrobial agents.
Outside of direct patient care, stewardship teams also provide clinician education and resources. For example, stewardship teams generate hospital antibiograms, which will allow clinicians to assess local resistance patterns at their hospitals to make informed decisions on antibiotic therapy. Beyond this valuable tool, stewardship teams are often involved in academic research initiatives to investigate new ways of combating antimicrobial resistance.
The global impact of antimicrobial resistance is staggering. In 2019, the United Nations Ad hoc Interagency Coordinating Group on Antimicrobial Resistance released a report and predicted that 10 million deaths per year will be attributed to antimicrobial resistance by 2050. This is exacerbated by the fact that fewer and fewer new antibiotic agents are being developed to replace existing agents that are now less effective due to increasing resistance rates. With a growing number of once preventable infections becoming untreatable, appropriate antimicrobial usage is gradually being recognized.
The overuse of antibiotics has only been amplified with COVID-19, which carries with it a risk of bacterial co-infection. For example, a rapid review of the literature published in May 2020 revealed that 72% of hospitalized COVID-19 patients received antibiotics, but only 8% were seen to have co-infections of a bacterial or other non-viral source. This is of major concern, as the pandemic seems to aggravate unnecessary antibiotic use.
Taking action now
The dangers of antimicrobial resistance are clear, and effective antimicrobial stewardship programs are more important now than ever, especially with the increased usage of antibiotics during the COVID-19 pandemic. Targeted training for healthcare professionals to differentiate between severe COVID-19 cases and cases of co-infections involving bacterial non-viral sources is a potential intervention.
Without taking direct action against the rise of resistance, the prevalence of multi-drug resistant organisms will increase. The result will be a wide array of previously treatable diseases becoming untreatable, leading to millions of unnecessary deaths in the future. As the world prepares for future waves of the pandemic, clinicians need to be more diligent and be active members of antimicrobial stewardship programs.
Resources for Canadians
The Public Health Agency of Canada recently published a Canada Communicable Disease Report (CCDR) in January 2020, featuring Antimicrobial Stewardship in Health Care Settings available here). In addition, Using Antibiotics Wisely is a national campaign where tools and resources are available for healthcare professionals and patients to learn more about unnecessary and inappropriate antibiotic use in primary care, long-term care, and hospital care settings.
Peter Zhang is a combined PharmD/MBA Student at the Leslie Dan Faculty of Pharmacy (LDFP) and the Rotman School of Management, University of Toronto; Corlissa Chan is a PharmD Student at the LDFP, University of Toronto; and Certina Ho is an Assistant Professor at the Department of Psychiatry and the LDFP, University of Toronto.