Commentary

ASPs exemplify ID field's positive impact on patients and public health

by Infectious Diseases Society of America

Antimicrobial stewardship improves patient outcomes, protects public health and elevates the field of infectious diseases. Despite its significant benefits, there are important opportunities for improvement and the Infectious Diseases Society of America is committed to strengthening stewardship implementation through collaborative, evidence-based approaches.

An overwhelming amount of data indicate that antimicrobial stewardship programs (ASPs) improve patient outcomes. ASPs have demonstrated better cure rates, fewer treatment failures, shorter lengths of stay in the hospital and shorter duration of fever. Numerous studies have found that stewardship interventions have led to significant reductions in Clostridioides difficile infections. ASPs benefit all of society by reducing the development of antimicrobial resistance that threatens to undo decades of medical progress. Multiple systematic reviews have concluded that ASPs have significant value with beneficial clinical and economic impacts, including clinical outcomes, adverse effects, cost and bacterial resistance rates.

IDSA recommends that ASPs be led by infectious disease physicians in partnership with pharmacists and multidisciplinary teams including clinical microbiologists and infection preventionists. Stewardship programs elevate our specialty by showcasing our expertise and provide more career opportunities for ID physicians. IDSA provides several educational resources to help ID physicians learn more about stewardship. Our leadership of stewardship is essential when considering that many antimicrobial drugs are not prescribed by ID physicians but by others who rely on our expertise.

Stewards must build strong relationships and trust with their colleagues — including our ID physician colleagues. Conversation among Emerging Infections Network users in 2015 noted that, “… authoritarian approaches and overruling of clinical judgment are potentially disastrous.” Many physicians report great satisfaction with stewardship programs given the educational opportunities and patient benefits they provide. More recently, a rounding-based, in-person approach to feedback by a pharmacist-physician team coined “handshake stewardship” has been shown to be effective in improving antibiotic use and well received by providers. Further, in the experiences of our experts, pharmacists who co-lead ASPs with ID physicians are respectful and collaborative and rely on the medical expertise of the ID ASP physician whenever appropriate. Recommendations from ASPs are often voluntary, particularly for other ID physicians.

Within the field of ID, there are specific subsets of expertise. An ID physician who has focused their career on stewardship likely knows more about antibiotic selection than one who has not, just as ID physicians who have focused their careers in HIV, transplant medicine or other aspects of ID have developed greater expertise in those areas. As ID becomes increasingly sophisticated, subspecialties increasingly become the norm.

There are undoubtedly opportunities to improve antibiotic stewardship and the related issues of appropriate availability of antimicrobials. IDSA advocates for greater investments from the federal government and health care institutions to ensure stewardship programs have the staffing and resources they need for optimal results, as well as for more research to advance the science of stewardship. We have made IDWeek the leading destination for stewardship science. Our Antimicrobial Stewardship Centers of Excellence program further spotlights the leaders in this field to serve as a model for all.

IDSA is deeply concerned that some patients do not receive the antimicrobial therapy they need. Some clinicians accept at face value the misperception that use of newer, more expensive agents is not in accordance with practicing stewardship; this idea represents a false dichotomy. Appropriate selection and timely administration of initial therapy is critical and has a major impact on outcomes, including risk for death. Given the effectiveness of newer agents against pathogens that have developed resistance to established agents, the use of newer agents in appropriately selected patients is compatible with good clinical care and stewardship.

Although stewardship decisions are not driven by cost, other hospital decision-makers are, in some instances, restricting use of new antibiotics due to cost. IDSA is advocating to strengthen Medicare reimbursement for antibiotics in order to remove the barrier of cost and better allow for optimal antibiotic use. In addition, uptake of new antibiotics is slowed by lack of data about how new antibiotics will perform in the patients who most need them. IDSA also advocates for funding for research to help inform the most appropriate use of new antibiotics.

One of the reasons the field of ID is so deeply gratifying is our ability to impact the patients we directly serve, as well as the broader population. Antimicrobial stewardship exemplifies this approach. Indeed, the ability to help protect the foundation of modern medicine by safeguarding the effectiveness of antibiotics for current and future physicians is a goal to which we should all be committed.

Editor's note: This commentary is a response to the editorial “ASPs: Who is smarter, the consultant of the curbside?” by Infectious Disease News Editorial Board Member Stephen M. Smith, MD. To read that article, click here.

References:

Baur D, et al. Lancet Infect Dis. 2017;doi:10.1016/S1473-3099(17)30325-0.

Carling P, et al. Infect Control Hosp Epidemiol. 2015;doi:10.1086/502278.

Davey P, et al. Cochrane Database Syst Rev. 2017;doi:10.1002/14651858.CD003543.pub4.

Dortch MJ, et al. Surg Infect. 2011;doi:10.1089/sur.2009.059.

Elligsen, et al. Infect Control Hosp Epidemiol. 2012;10.1086/664757.

Grant EM, et al. Pharmacotherapy. 2002;doi:10.1592/phco.22.7.471.33665.

Gross R, et al. Clin Infect Dis. 2001;doi:10.1086/321880.

Kullar R, et al. Pharmacotherapy. 2013;doi:10.1002/phar.1220.

Lipworth AD, et al. Infect Control Hosp Epidemiol. 2006;doi:10.1086/503016.

Malani AN, et al. Am J Infect Control. 2013;10.1016/j.ajic.2012.02.021.

Nathwani D, et al. Antimicrob Resist Infect Control. 2019;doi:10.1186/s13756-019-0471-0.

Schuts EC, et al. Lancet Infect Dis. 2016;doi:10.1016/S1473-3099(16)00065-7.

Wenzler E, et al. Antibiotics (Basel). 2015;doi:10.3390/antibiotics4020198.

by Infectious Diseases Society of America

Antimicrobial stewardship improves patient outcomes, protects public health and elevates the field of infectious diseases. Despite its significant benefits, there are important opportunities for improvement and the Infectious Diseases Society of America is committed to strengthening stewardship implementation through collaborative, evidence-based approaches.

An overwhelming amount of data indicate that antimicrobial stewardship programs (ASPs) improve patient outcomes. ASPs have demonstrated better cure rates, fewer treatment failures, shorter lengths of stay in the hospital and shorter duration of fever. Numerous studies have found that stewardship interventions have led to significant reductions in Clostridioides difficile infections. ASPs benefit all of society by reducing the development of antimicrobial resistance that threatens to undo decades of medical progress. Multiple systematic reviews have concluded that ASPs have significant value with beneficial clinical and economic impacts, including clinical outcomes, adverse effects, cost and bacterial resistance rates.

IDSA recommends that ASPs be led by infectious disease physicians in partnership with pharmacists and multidisciplinary teams including clinical microbiologists and infection preventionists. Stewardship programs elevate our specialty by showcasing our expertise and provide more career opportunities for ID physicians. IDSA provides several educational resources to help ID physicians learn more about stewardship. Our leadership of stewardship is essential when considering that many antimicrobial drugs are not prescribed by ID physicians but by others who rely on our expertise.

Stewards must build strong relationships and trust with their colleagues — including our ID physician colleagues. Conversation among Emerging Infections Network users in 2015 noted that, “… authoritarian approaches and overruling of clinical judgment are potentially disastrous.” Many physicians report great satisfaction with stewardship programs given the educational opportunities and patient benefits they provide. More recently, a rounding-based, in-person approach to feedback by a pharmacist-physician team coined “handshake stewardship” has been shown to be effective in improving antibiotic use and well received by providers. Further, in the experiences of our experts, pharmacists who co-lead ASPs with ID physicians are respectful and collaborative and rely on the medical expertise of the ID ASP physician whenever appropriate. Recommendations from ASPs are often voluntary, particularly for other ID physicians.

Within the field of ID, there are specific subsets of expertise. An ID physician who has focused their career on stewardship likely knows more about antibiotic selection than one who has not, just as ID physicians who have focused their careers in HIV, transplant medicine or other aspects of ID have developed greater expertise in those areas. As ID becomes increasingly sophisticated, subspecialties increasingly become the norm.

There are undoubtedly opportunities to improve antibiotic stewardship and the related issues of appropriate availability of antimicrobials. IDSA advocates for greater investments from the federal government and health care institutions to ensure stewardship programs have the staffing and resources they need for optimal results, as well as for more research to advance the science of stewardship. We have made IDWeek the leading destination for stewardship science. Our Antimicrobial Stewardship Centers of Excellence program further spotlights the leaders in this field to serve as a model for all.

IDSA is deeply concerned that some patients do not receive the antimicrobial therapy they need. Some clinicians accept at face value the misperception that use of newer, more expensive agents is not in accordance with practicing stewardship; this idea represents a false dichotomy. Appropriate selection and timely administration of initial therapy is critical and has a major impact on outcomes, including risk for death. Given the effectiveness of newer agents against pathogens that have developed resistance to established agents, the use of newer agents in appropriately selected patients is compatible with good clinical care and stewardship.

Although stewardship decisions are not driven by cost, other hospital decision-makers are, in some instances, restricting use of new antibiotics due to cost. IDSA is advocating to strengthen Medicare reimbursement for antibiotics in order to remove the barrier of cost and better allow for optimal antibiotic use. In addition, uptake of new antibiotics is slowed by lack of data about how new antibiotics will perform in the patients who most need them. IDSA also advocates for funding for research to help inform the most appropriate use of new antibiotics.

One of the reasons the field of ID is so deeply gratifying is our ability to impact the patients we directly serve, as well as the broader population. Antimicrobial stewardship exemplifies this approach. Indeed, the ability to help protect the foundation of modern medicine by safeguarding the effectiveness of antibiotics for current and future physicians is a goal to which we should all be committed.

Editor's note: This commentary is a response to the editorial “ASPs: Who is smarter, the consultant of the curbside?” by Infectious Disease News Editorial Board Member Stephen M. Smith, MD. To read that article, click here.

References:

Baur D, et al. Lancet Infect Dis. 2017;doi:10.1016/S1473-3099(17)30325-0.

Carling P, et al. Infect Control Hosp Epidemiol. 2015;doi:10.1086/502278.

Davey P, et al. Cochrane Database Syst Rev. 2017;doi:10.1002/14651858.CD003543.pub4.

Dortch MJ, et al. Surg Infect. 2011;doi:10.1089/sur.2009.059.

Elligsen, et al. Infect Control Hosp Epidemiol. 2012;10.1086/664757.

Grant EM, et al. Pharmacotherapy. 2002;doi:10.1592/phco.22.7.471.33665.

Gross R, et al. Clin Infect Dis. 2001;doi:10.1086/321880.

Kullar R, et al. Pharmacotherapy. 2013;doi:10.1002/phar.1220.

Lipworth AD, et al. Infect Control Hosp Epidemiol. 2006;doi:10.1086/503016.

Malani AN, et al. Am J Infect Control. 2013;10.1016/j.ajic.2012.02.021.

Nathwani D, et al. Antimicrob Resist Infect Control. 2019;doi:10.1186/s13756-019-0471-0.

Schuts EC, et al. Lancet Infect Dis. 2016;doi:10.1016/S1473-3099(16)00065-7.

Wenzler E, et al. Antibiotics (Basel). 2015;doi:10.3390/antibiotics4020198.