Antimicrobial stewardship programs guidelines

Core Elements of Outpatient Antibiotic Stewardship. Top of Page. To receive email updates about this page, enter your email address: Email Address. What's this? Links with this icon indicate that you are leaving the CDC website.

Linking to a non-federal website does not constitute an endorsement by CDC or any of its employees of the sponsors or the information and products presented on the website. One study involved cellulitis and cutaneous abscesses [ 47 ]. Several of these studies described a process of interdisciplinary guideline development along with a multifaceted dissemination and implementation strategy to increase awareness and uptake of the guideline [ 40 , 43 , 45 , 47 ].

Such strategies included guideline dissemination in electronic or hard-copy formats, provider education, engagement of peer champion advocates, audit and feedback of prescribing practices to providers, checklists, and incorporation of recommendations into electronic order sets.

Specific improvements in antibiotic use associated with implementation of facility-specific guidelines have included statistically significant increases in likelihood of adequate initial therapy [ 40 , 46 ], use of narrower-spectrum antibiotic regimens [ 41 , 42 , 47 ], earlier switch from IV to oral therapy [ 39 ], and shorter duration of treatment [ 39 , 41 , 45 — 47 ]—all without adverse effects on other clinical outcomes.

For those studies powered to detect differences in clinical outcomes, reductions in mortality [ 40 ], length of hospital stay [ 39 — 41 , 43 , 44 ], adverse events [ 39 , 48 ], recurrence or readmission [ 46 ], and treatment costs [ 40 , 44 ] have been demonstrated. The sustainability of the effects of guideline implementation has not been well established. In one study, changes in prescribing and outcomes were sustained 3 years after guideline implementation [ 43 ]; however, in another study, removal of measures to promote guideline adherence after 1 year was associated with a reduction in adherence [ 49 ].

Therefore, interventions to maintain guideline adherence over time may be necessary, and intended outcomes should be monitored. In addition to hospital-wide activities, such as preauthorization or development of clinical guidelines, a strategy for targeted efforts to improve antibiotic use and clinical outcomes for a specific infectious diseases issue has been shown to be effective.

For example, to reduce the use of broad-spectrum therapy and shorten the duration of treatment for adults with uncomplicated SSTIs, an intervention was developed that included dissemination of a treatment algorithm, electronic order sets, recruitment of physician champions, and quarterly feedback to providers of compliance with the guideline.

Interventions to reduce inappropriate treatment of ASB at geriatric or long-term care institutions have resulted in significant decreases in antibiotic use [ 50 , 51 ]. For example, Zabarsky et al [ 50 ] developed an intervention that discouraged both nurses from collecting urine cultures from asymptomatic patients and primary care providers from treating ASB. After the intervention, urine cultures decreased from 2.

The improvements were sustained for 30 months of follow-up. ASP interventions for CAP have increased the proportion of patients receiving appropriate therapy There was no difference between the baseline and intervention periods in the proportions of patients who were readmitted within 30 days In a study involving 5 hospitals, implementation of a guideline that included criteria for oral conversion and hospital discharge reduced length of stay from 7.

An alternative approach is assessing patients with blood cultures growing specific pathogens. Patients with bacteria or yeast in their blood can usually be identified through communication with the microbiology laboratory or through alerts from computerized surveillance systems. For example, Antworth et al [ 55 ] described the impact of a candidemia-care bundle in which patients were identified by electronic medical records and clinical microbiology reports.

In a study targeting gram-negative bacteremia, Pogue et al [ 57 ] combined active alerting of positive blood cultures with ASP intervention.

In the subgroup of patients not on appropriate antibiotic therapy at the time of the initial positive blood culture, the intervention was associated with reduced mortality odds ratio [OR], 0. More recent studies have been conducted in a variety of hospital settings. Some have been prompted by outbreaks [ 59 , 65 ], whereas others were performed in endemic situations [ 22 , 63 ].

Implementation of ASPs has been associated with statistically significant sudden or linear-trend decreases in nosocomial CDI rates [ 22 , 58 — 61 , 63 — 65 ], which have been sustained for up to 7 years [ 22 ]. A meta-analysis [ 18 ] highlights the effectiveness of stewardship for CDI prevention and outlines ASP intervention strategies. Other studies support that antibiotic restriction can further reduce CDI rates when added to previous infection control measures [ 58 , 59 ].

In fact, Valiquette et al [ 59 ] reported that simply strengthening basic infection control measures did not reduce the CDI rate. Strategies to prompt prescribers to assess antibiotic therapy without formal ASP intervention have undergone only limited evaluation. Checklists to guide process of care in a medical ICU have been studied [ 67 , 68 ].

In one study [ 67 ], physicians received face-to-face prompting if they overlooked the antibiotic review on the checklist. Prompting improved compliance with the checklist and was associated with a reduced duration of antibiotic therapy and a lower risk-adjusted mortality than no prompting in patients receiving empiric antibiotics OR, 0. Even with prompting, prescribers may have difficulty performing self-stewardship.

For example, in a study by Lesprit et al [ 69 ], clinicians were prompted to review IV therapy at 72 hours. There was no significant change in the frequency of antibiotic regimen modification compared with the control group; however, requests for infectious diseases input increased. Antibiotic stop orders are another approach to requiring physicians to review their antibiotic use. This has been best studied for 3-day stop orders for vancomycin [ 70 , 71 ].

Hospital-wide vancomycin use decreased as well g vs — g per patient-days; P not stated [ 70 ]. A safety mechanism should be paired with stop orders to avoid unintended interruptions and to prevent alienating prescribers against antibiotic stewardship interventions. Collectively, these findings suggest that antibiotic review by the prescriber can have an important stewardship impact if done with appropriate reminders or prompting, but available data do not confirm feasibility or sustainability.

Computerized decision support systems are designed to improve antibiotic use by providing treatment recommendations to clinicians at the time of prescribing [ 72 — 77 ]. Implementation of computerized decision support systems for prescribers has been associated with reduced use of broad-spectrum antibiotics [ 73 , 74 ], improved antibiotic dosing [ 75 ], reduced antibiotic resistance [ 74 ], more appropriate antibiotic selection [ 73 , 77 ], fewer prescribing errors [ 72 , 75 , 78 ], reduced adverse events [ 72 , 76 ], reduced antibiotic costs [ 72 , 73 , 75 , 76 ], reduced length of stay [ 72 ], and reduced mortality [ 76 ].

Computerized surveillance systems for ASPs may improve efficiency by facilitating more PAF interventions and reducing the time for such interventions [ 79 — 81 ]. Use of those systems by ASPs has been associated with reduced use of broad-spectrum antibiotics [ 81 ] and reduced antibiotic costs [ 79 ].

Antibiotic cycling involves withdrawal of an antibiotic or antibiotic class from general use within a ward or an institution for a designated period of time and substitution with antibiotics from a different class having a comparable spectrum of activity but for which bacteria may have different resistance mechanisms.

Antibiotic cycling is difficult to achieve, labor intensive, and impractical for most inpatient facilities. Many studies have been performed, but they fail to provide compelling evidence of the benefit of antibiotic cycling, partly because of methodologic shortcomings.

Common weaknesses include single-center setting usually in ICUs , before-and-after time-series analysis, lack of adherence to prescribing protocols, multiple simultaneous interventions including infection prevention and guideline implementation , and lack of long-term follow-up.

Brown and Nathwani [ 82 ] performed a systematic review of antibiotic cycling in and concluded that available study results did not permit conclusions regarding the efficacy of cycling. In contrast to cycling that is performed at the level of the medical facility or patient care ward, a strategy known as antibiotic mixing is performed at the level of the individual patient, in which consecutive patients with the same diagnosis receive an antibiotic from a different class in rotation.

Mathematical modeling suggests that antibiotic mixing is a more promising strategy for limiting emergence of resistance than cycling, but few clinical studies validate these models [ 83 , 84 ].

Comprehensive reviews published in [ 85 , 86 ] concluded that more work is needed to demonstrate the usefulness of antibiotic mixing. In randomized studies, individualized PK monitoring and adjustment of aminoglycoside dosing compared with standard dosing is associated with increased likelihood of obtaining serum concentrations within therapeutic range [ 87 , 88 ] and reduced institutional costs [ 87 , 89 ].

Reductions in nephrotoxicity, hospital length of stay, and mortality [ 87 , 90 — 92 ] have been observed in some studies. Leehey et al [ 88 ] randomized patients receiving aminoglycosides to dosing directed by one of 3 groups: 1 physicians with PK monitoring input from a pharmacist; 2 physician—pharmacist PK monitoring team; or 3 physicians with no external input control group.

Bartal et al [ 90 ] compared the outcomes of usual care vs an intensive PK monitoring program among patients receiving initial high-dose extended-interval gentamicin dosing. Only one randomized controlled study [ 93 ] has been performed assessing the impact of a PK monitoring and adjustment program for vancomycin; no difference in efficacy in the concentration-monitoring arm was demonstrated, but there was a lower incidence of nephrotoxicity adjusted OR, 0.

Observational studies [ 93 — 96 ] of vancomycin dose individualization showed similar effects, with costs stable or lower. Broader interventions directed at antibiotic dosing, usually involving integration of dosing support into computerized physician order-entry systems, have shown improved adherence to dosing guidelines as well as fewer adverse effects, but no difference in effectiveness eg, clinical cure, hospital mortality, or length of stay [ 97 — 99 ].

No studies have examined the relationship between PK monitoring and adjustment programs and institutional antibiotic resistance prevalence. For vancomycin, continuous infusion has not been shown to improve clinical outcomes in adults but has been associated with decreased nephrotoxicity in a meta-analysis [ ]. Similarly, continuous-infusion vancomycin has been associated with few adverse effects and no nephrotoxicity in children [ ].

The findings of many studies [ — ] have shown that programs aimed to increase the use of oral antibiotics are associated with reduced drug costs and length of hospital stay without compromising efficacy or safety. There were no differences in clinical course, cure rate, survival, or resolution of chest radiographs [ ].

Unlike automatic conversion from IV to oral formulations of the same antibiotic, switching from IV antibiotics without an equivalent oral formulation needs more advanced assistance. This might have been partly attributable to the lack of precise recommendations for switching when an oral equivalent was not available eg, piperacillin-tazobactam or meropenem as switching occurred less often in such patients.

They directed providers to seek infectious diseases consultation for patients on IV formulations without an oral equivalent. ASPs can have an important role with more complicated IV-to-oral transitions. Another example of the potential benefit of IV-to-oral transition is reduction in the need for outpatient parenteral antibiotic therapy OPAT. Compared with nonallergic patients, patients labeled as having a PCN allergy are exposed to more alternative antibiotics; have increased prevalence of C.

Using structured drug allergy assessments has been associated with improved antibiotic stewardship as demonstrated by antibiotic selection, reduced alternative antibiotic use, decreased length of hospital stay and costs, and increased guideline adherence [ , ]. ASPs should encourage mechanisms that ensure allergy assessments are performed. Findings from 2 pre—post investigations suggest that antibiotic stewardship interventions aimed at reducing the duration of antibiotic therapy lead to similar clinical outcomes compared with the preintervention period.

For VAP due to nonfermenting gram-negative bacilli, however, shorter course was associated with more recurrences OR, 2. Institutional antibiograms are helpful to ASPs for the development of guidelines for empiric therapy. The Clinical and Laboratory Standards Institute [ ] provides guidelines for antibiogram construction and reporting, both for routine cumulative antibiograms and for enhanced antibiograms, which may be stratified by various parameters including patient location or population if at least 30 isolates are available for each organism.

A single institutional, or hospital-wide, antibiogram may mask important susceptibility differences across units within the institution.

For example, certain antibiotic-resistant organisms are often significantly more common in ICU than in non-ICU settings. At one medical center, the percentages of bacterial isolates resistant to antibiotics were significantly higher in medical and surgical ICUs than were those predicted by the hospital-wide antibiogram, whereas the percentage of isolates susceptible to antibiotics was higher in non-ICU units, compared with the hospital overall [ ].

Similarly, antibiograms can be stratified by population age group eg, pediatrics [ ], by infection site eg, blood or respiratory vs all sources [ , ], by patient comorbidities eg, cystic fibrosis [ ], or by acquisition in the community vs healthcare setting [ ]. One institution [ ] constructed a pediatric-specific antibiogram for Escherichia coli and compared it with antibiograms generated from combined data from both adult and pediatric isolates.

There were significant antibiotic susceptibility differences between E. Provision of pediatric-specific data optimized prescribing choice when compared with no antibiogram and also with the hospital-wide antibiogram. Another institution [ ] also found age-specific differences with overestimation of resistance in E. Selective reporting is the practice of reporting susceptibility results for a limited number of antibiotics instead of all tested antibiotics. For example, a laboratory that practices selective reporting would routinely release linezolid and daptomycin results only when enterococci are nonsusceptible to ampicillin and vancomycin.

In a randomized study for urinary tract infections, Coupat et al [ ] used a case-vignette format and randomly assigned residents to an intervention group, which received antibiotic susceptibility results for 2—4 antibiotics, or to a control group, which received full-length results for all 25 antibiotics tested. Similar results have been seen in some prospective surveys [ , ]. Cascade reporting is one type of selective reporting in which susceptibility results of secondary antibiotics either more costly or broader spectrum are only reported if an organism is resistant to the primary antibiotic within the particular antibiotic class eg, if the organism is cefazolin susceptible, ceftriaxone would not be reported.

There are no published guidelines for cascade antibiotic reporting. The Clinical and Laboratory Standards Institute [ ] provides guidance for testing and reporting susceptibilities for certain organisms, but does not cover all organism-antibiotic combinations. ASPs should work with the microbiology laboratory to assess the impact these strategies may have on development of the antibiogram eg, susceptibility data for suppressed results may not be available for inclusion.

Studies of the value of ASP interventions based on rapid testing for respiratory viruses are lacking. However, some data are available on decreased inappropriate antibiotic use with rapid viral testing. Those studies have been performed primarily in pediatric populations such as children presenting to physicians' offices [ ] or emergency departments [ — ], or children requiring hospitalization [ ].

One study focused specifically on immunocompromised children [ ] and 2 focused on adults [ , ]. Findings from some trials showed that rapid diagnostic testing for respiratory viruses by rapid antigen, rapid immunoassay, or direct fluorescent antigen was associated with decreased ancillary test orders eg, chest radiograph, urinalysis [ , ], decreased antibiotic use [ , , , , ], and increased antiviral use [ , , ].

There was no impact on the above outcomes for patients with negative rapid test results. Other studies [ , ], however, have failed to detect statistically significant benefits in antibiotic use, hospital stays, or hospital admissions when reporting PCR or direct fluorescent antigen results. The lack of an appreciable benefit was attributable in part to the time to reporting of PCR results, which ranged from 12 to 24 hours in one study [ ] to a mean of 30 hours in another study [ ].

The use of rapid molecular assays and mass spectrometry to identify bacterial species and susceptibility in blood cultures has been associated with statistically significant improvements in time to initiation of appropriate antibiotic therapy [ — ], rates of recurrent infection [ ], mortality [ , ], length of stay [ , ], and hospital costs [ , ].

Compared with pre—PNA-FISH, rapid testing coupled with antibiotic stewardship team support was associated with more rapid identification of Enterococcus faecalis 1. In the study by Huang et al [ ], the stewardship team received immediate notification of blood culture Gram stain, MALDI-TOF identification, and susceptibility results, and then gave recommendations.

These interventions were not, however, associated with improved mortality, length of stay, or cost, possibly because of the use of other rapid tests and ASP support at the institution. These studies underscore the importance of combining use of rapid testing with 2 strategies to maximize the benefits and likelihood of a favorable impact on outcomes. First, ASP support [ — ] or rapid notification of results [ , ] was a consistent feature of the studies that found statistically significant associations between rapid testing and outcomes.

In contrast, studies lacking these features often did not find evidence of associations between rapid testing and improved antibiotic use [ ], time to initiation of appropriate antibiotic therapy [ ], or length of stay benefit [ ]—despite shortening the time to pathogen identification.

The optimal implementation of rapid testing requires increased laboratory resources and additional costs. PCT has been assessed for its role in 1 shortening the duration of antibiotic therapy for bacterial infection based on serial measurements of PCT levels, and 2 avoidance of initiation of antibiotic therapy when the PCT level is low.

Evidence from several prospective RCTs supports the use of PCT in decisions concerning discontinuation of antibiotic therapy in critically ill patients in ICUs [ — ]. In general, trials assessing PCT-guided discontinuation of antibiotic therapy report significantly more antibiotic-free days 2—4 days in the PCT arm, without a negative effect on mortality. A meta-analysis focusing exclusively on critically ill ICU patients with severe sepsis or septic shock including 7 studies and patients showed no significant difference in day mortality or hospital mortality and a median reduction of approximately 2 days in the length of antibiotic therapy with PCT guidance [ ].

In a European multicenter study, Bouadma et al [ ] examined de-escalation of therapy in septic patients and demonstrated 2. Available evidence does not support the use of PCT to avoid initiation of antibiotics in the critically ill ICU population when the PCT result is negative [ , ]. In patients with hematologic malignancy at risk of contracting IFD, we suggest incorporating nonculture-based fungal markers in ASP interventions to optimize antifungal use weak recommendation, low-quality evidence.

Some studies have demonstrated that the use of nonculture-based fungal markers can safely reduce antifungal treatments for patients with hematologic malignancy at high risk for IFD. Although not specifically studied as part of an ASP intervention, incorporation into existing ASPs for antifungal stewardship in that population may be useful.

For example, Cordonnier et al [ ] compared a preemptive approach antifungal treatment initiation using both clinical and GM evidence of IFD with an empiric strategy antifungal treatment for any high-risk patient with suggestive clinical signs of IFD. The preemptive approach was associated with decreased antifungal treatment An RCT [ ] of Aspergillus and Candida PCR compared survival between allogeneic stem cell transplant recipients who received empiric antifungal treatment with those who received empiric plus PCR-based antifungal treatment.

The authors demonstrated improved day survival in the group in which treatment decisions were in part based upon PCR, but survival did not differ by day There are limited data assessing the value of fungal markers in other patient populations.

Pediatric data are limited, but studies [ ] have shown that GM assay is a useful adjunctive tool when monitored twice weekly in hospitalized children with hematologic malignancies and fever. We suggest monitoring antibiotic use as measured by DOTs in preference to DDD weak recommendation, low-quality evidence. Both are useful for facility-level monitoring and interfacility comparisons.

DOTs have some important advantages. DOTs are not impacted by dose adjustments and can be used in both adult and pediatric populations, whereas DDDs have more limited use in pediatrics due to weight-based dosing.

DOTs, however, require patient-level antibiotic use data, which currently may not be feasible at every facility [ — ]. Either method can be used to examine overall use or specific use by unit, provider, or service in the hospital. In addition to measurement of antibiotic use, appropriateness of prescribing can be assessed by determining compliance with facility-specific antibiotic treatment guidelines. This is particularly useful when assessing the success of a targeted intervention.

Measurement of ASP impact on patient outcomes is important but is more challenging than measurement of antibiotic use or guideline compliance. For example, using CDI rates to measure the effectiveness of stewardship interventions has significant limitations. Although implementation of ASPs has been associated with reduced CDI rates in quasi-experimental studies [ 18 ], the quantitative relationships between changes in antibiotic use and CDI incidence are largely unknown.

Because CDI rates are affected by other practices besides antibiotic use, such as compliance with infection control measures, they may be a relatively insensitive metric for judging the effectiveness of ASPs.

Moreover, traditional statistical techniques have significant limitations when applied to nonindependent events such as CDI. Despite this, when implementing ASP interventions directed at reduction of antibiotics considered to be high risk for promoting CDI eg, cephalosporins, clindamycin, fluoroquinolones , including rates of healthcare-facility-onset CDI as a secondary outcome measure is recommended in that population.

Antibiotic resistance is an even more complex metric than CDI because the development and spread of resistance is impacted by many factors. Implementation of stewardship interventions has been associated with reduced resistance in both gram-positive and gram-negative bacteria [ 34 ]; however, observed effects on resistance are unpredictable because of confounding variables and many pathogen and host factors.

Still, measurement of resistance may be useful for selected bacterial pathogens and in focused patient populations receiving a targeted ASP intervention.

ASPs have the potential to decrease length of stay, primarily as a consequence of timely switching from IV to oral antibiotics or by stopping unnecessary IV antibiotics; however, the impact depends on the preexisting contribution of prolonged administration of parenteral antibiotics to excess length of stay.

Days of hospitalization avoided is a better measure of the effectiveness of ASP. Parenteral therapy and days of central venous access avoided are other metrics that can be useful. ASPs result in cost savings for facilities [ ]. It is important to monitor program costs in addition to measuring antibiotic use as one way to justify continued administrative support for ASP activities. Antibiotic costs should be measured based on prescriptions or administrations instead of purchasing data [ ] and normalized to account for patient census eg, antibiotic cost per patient-day [ ].

Program costs eg, salary for stewardship personnel [ 19 , ] and adjustment for inflation or standardizing costs across years [ ] should be considered.

Analyses that measure the effects of an intervention over time should compare actual costs after the initiation of the intervention vs projected costs in the absence of the intervention, as direct cost reductions tend to plateau [ , ]. More robust analyses include expenditures beyond drug acquisition such as those for drug administration, therapeutic drug monitoring, and toxicities [ ].

If resources are available, programs should analyze broader effects on budgets, such as total hospitalization costs [ 58 , , ]. For example, interventions designed to increase compliance with a guideline should evaluate the proportion of patients in each period who are compliant.

Evidence of unintended negative effects such as hospital readmission or increase in rates of hospital-acquired CDI should also be monitored. The major limitation to these metrics is the availability of reliable data. Sources: [ 39 , 50 — 57 , — ]. Success rates for empiric regimen, time to defervescence, duration of antibiotic therapy, and death rates were similar before and after guideline adoption.

No deaths were attributed to infections due to gram-positive organisms [ ]. Studies have shown that adherence to treatment guidelines resulted in improvement in important clinical outcomes. For example, Pakakasama et al [ ] demonstrated that implementation of clinical guidelines in pediatric cancer patients resulted in statistically significant reductions in septic shock intervention vs control: 3. In another study [ ], adherence to an ASP protocol for initial antibiotic therapy based on IDSA guidelines was associated with lower mortality hazard ratio, 0.

Those interventions must be done in close collaboration with the primary teams eg, hematology-oncology, solid organ transplant providers. Programs that have successfully implemented antifungal stewardship interventions have used a multipronged approach that included PAF, education, and development of clinical guidelines [ — ].

Published studies have not focused exclusively on immunocompromised patients, but those patients accounted for the largest group in most reports. Patients in the ICU made up the second-largest group. Process of care measures for the management of candidemia and aspergillosis eg, optimal voriconazole monitoring, use of recommended first-line therapy improved.

The total cost of antifungals was considered to be stable and actually decreased in the year just after the formal study ended. In a second study [ ], the stewardship team focused on high-cost antifungals at a tertiary hospital in patients over a month period.

Nursing homes are significant reservoirs for multidrug-resistant organisms [ ]. Developing approaches to improve antibiotic use is important; however, few studies have shown an impact on clinical outcomes. Jump et al [ ] reported a decrease in systemic antibiotic use by This model, however, may not be possible in many US nursing homes given resource restraints such as lack of finances, availability of an infectious diseases physician, and interest. Schwartz et al [ ] conducted an intervention that included physician education, guideline implementation, and presentation of local baseline antibiotic use data in a public long-term care facility with 20 salaried internists.

Antibiotic starts decreased by This level of physician staffing, however, is not typical of most facilities. Stewardship interventions inclusive of the nursing staff have been successful in reducing antibiotic use, but the effect on clinical outcome is not usually reported.

Fleet et al [ ] evaluated the impact of the Resident Antimicrobial Management Plan at 30 nursing homes in England. The nursing staff received written educational materials and used this tool to record compliance with good practice points at treatment initiation and 48—72 hours later. Antibiotic consumption over 12 weeks decreased by 4. Loeb et al [ ] studied a multifaceted educational intervention for urinary tract infections that included a diagnostic and treatment algorithm at 24 nursing homes in Ontario, Canada and Idaho.

Antibiotic use for suspected urinary tract infection was lower at intervention than at usual-care nursing homes 1. Zimmerman et al [ ] assessed a quality improvement program at 12 nursing homes in North Carolina. This multifaceted program consisted of guideline education for providers, sensitization to antibiotic prescribing matters for nursing staff and family members, and prescribing feedback for providers and nursing staff. Between baseline and follow-up at 9 months, prescription rates dropped more at intervention homes Antibiotic policy and guidelines have been shown to be effective in the NICU [ ].

Zingg et al [ ] evaluated antibiotic use after initiating a policy to shorten antibiotic therapy for sepsis and coagulase-negative staphylococcal infection, and to stop preemptive treatment if blood cultures were negative. They found an overall 2. Antibiotic restriction interventions can be successful in the NICU. The proportion of ampicillin use increased from End of life is defined as the final days or weeks of life in patients under hospice care where the primary goals are managing symptoms, improving comfort, and optimizing quality of life—not prolonging survival.

In contrast, palliative care is more general and can be pursued along with curative therapies. Antibiotic use, frequently with multiple antibiotics, is common in patients with terminal cancer. Therapy is often continued after transition to comfort care and discontinued less than 1 day prior to death [ ]. Patients with advanced dementia also have high exposure to antibiotics, especially in the weeks prior to death [ ].

Therefore, older adults with advanced dementia or who are in long-term care facilities [ ] and patients receiving end-of-life treatment in the ICU [ ] may become reservoirs for resistant bacteria.

For example, end-of-life antibiotic treatment in the ICU was independently associated with acquisition of resistant bacteria in a logistic regression analysis [ ]. For patients under hospice care, the impact of antibiotic therapy on symptom alleviation should be considered in the context of specific infections [ , ]. For example, treating urinary tract infection may improve dysuria and treating thrush may improve dysphagia [ , ], but the impact of antibiotics on the symptoms of respiratory tract infection is less clear [ — ].

In contrast, antibiotic treatment of pneumonia in nursing home residents with dementia was associated with fewer symptoms in 2 Dutch studies. Van der Steen et al [ ] reported that the level of discomfort was generally higher in patients for whom antibiotic therapy was withheld in nonsurvivors compared with surviving patients treated with antibiotics; however, those nonsurvivor patients had more discomfort before pneumonia developed. Subsequently, Van der Steen et al [ ] reported fewer symptoms if pneumonia was treated with antibiotics rather than just fluids in patients with dementia even if death was imminent; the majority of patients received oral therapy.

If prolonging survival is not a primary goal, withholding antibiotic agents should be considered. If treatment is desired, antibiotic agents should be administered orally whenever possible. Patients and their surrogates should be engaged in the decision to use antibiotic agents at end of life. Stiel et al [ ] reported that families of terminally ill cancer patients are often consulted about stopping antibiotics, but the decision to start therapy is usually made by clinicians without much discussion.

Similarly, Givens et al [ ] reported that most infectious episodes in nursing home residents with advanced dementia did not involve healthcare proxies in decision making. Given significant treatment burdens, potential for adverse effects such as CDI, and public health risks, antibiotic therapy should be viewed as aggressive care in the end-of-life setting.

This guideline discusses a broad range of possible ASP interventions. We have emphasized the need for each site to assess its clinical needs and available resources and individualize its ASP with that assessment in mind.

A powerful way to support antibiotic stewardship is to improve the scientific basis for ASP interventions. As outlined in Section XIII, ASPs can successfully intervene to reduce the duration of therapy for many infections because well-constructed, randomized controlled clinical trials have demonstrated that clinical outcomes are equivalent. Rigorous published evidence is often needed to convince clinicians to alter well-established, albeit suboptimal, practice. For example, ASPs can cite high-quality data to reduce unnecessary antibiotic treatment of uncomplicated diverticulitis [ ], or ASB eg, in women 60 years or younger, diabetic patients, or the elderly [ ].

Additional clinical trials that incorporate consideration of antibiotic stewardship in their design are critically needed. Another significant gap is the dearth of implementation research in this area [ 28 ]. Although the National Action Plan for Combating Antibiotic-Resistant Bacteria [ 6 ] will require the institution of ASPs across healthcare facilities, little effort and limited research funding have been allocated to study how best to achieve large-scale implementation.

There is inadequate information on the best model for an ASP. Although ASPs have studied application of a combination of interventions, they are not comparable to existing bundles because they require interpretation, expertise, and persuasion [ ].

A new or adapted model for ASP is likely needed and best developed through application of rigorous implementation science. Despite the recognition that much more research is needed, this guideline identifies core interventions for all ASPs as well as other interventions that can be implemented based on facility-specific assessments of need and resources. Every healthcare facility is able to perform stewardship, and institution of an ASP is attainable and of great importance to public health.

The expert panel expresses its gratitude to Drs Elizabeth Dodds Ashley, Annie Wong-Beringer, and Stan Deresinski for their thoughtful reviews of earlier drafts of the guideline. The panel greatly appreciates the work of Charles B.

Wessels and Michele Klein Fedyshin of the Health Sciences Library System of the University of Pittsburgh for the development and execution of the systematic literature searches for this guideline, and Jennifer J. Padberg, MPH, for her administrative assistance throughout the guideline development process. Financial support. Potential conflicts of interest. The following list is a reflection of what has been reported to IDSA. To provide thorough transparency, IDSA requires full disclosure of all relationships, regardless of relevancy to the guideline topic.

This assessment of disclosed relationships for possible COI will be based on the relative weight of the financial relationship ie, monetary amount and the relevance of the relationship ie, the degree to which an association might reasonably be interpreted by an independent observer as related to the topic or recommendation of consideration.

The reader of these guidelines should be mindful of this when the list of disclosures is reviewed. All other authors report no potential conflicts of interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed. National Center for Biotechnology Information , U.

Clin Infect Dis. Published online Apr Tamar F. Barlam , 1, a Sara E. Cosgrove , 2, a Lilian M. Schuetz , 5 Edward J. Septimus , 6 Arjun Srinivasan , 7 Timothy H. Dellit , 8 Yngve T. Falck-Ytter , 9 Neil O. Fishman , 10 Cindy W. Hamilton , 11 Timothy C.

Jenkins , 12 Pamela A. Lipsett , 13 Preeti N. Malani , 14 Larissa S. May , 15 Gregory J. Moran , 16 Melinda M. Neuhauser , 17 Jason G. Newland , 18 Christopher A. Ohl , 19 Matthew H. Samore , 20 Susan K. Seo , 21 and Kavita K. Trivedi Sara E. Lilian M. Audrey N. Edward J. Timothy H. Yngve T. Neil O. Cindy W. Timothy C. Pamela A. Preeti N. Larissa S. Gregory J. Melinda M. Jason G. Louis, Missouri Find articles by Jason G.

Christopher A. Matthew H. Susan K. Kavita K. Author information Article notes Copyright and License information Disclaimer. Contributed by a T. Contributed by It is important to realize that guidelines cannot always account for individual variation among patients.

Correspondence: T. Received Feb 22; Accepted Feb All rights reserved. For permissions, e-mail moc. This article has been cited by other articles in PMC. Abstract Evidence-based guidelines for implementation and measurement of antibiotic stewardship interventions in inpatient populations including long-term care were prepared by a multidisciplinary expert panel of the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America.

Keywords: antibiotic stewardship, antibiotic stewardship programs, antibiotics, implementation. Open in a separate window. Figure 1. Interventions I. Recommendation 1. Recommendation 2.

Recommendation 3. Recommendation 4. Recommendation 5. Recommendation 6. Recommendation 7. Recommendation 8. Recommendations 9. Recommendation Measurement XX. Consensus Development Based on Evidence The panel met face to face on 3 occasions and conducted numerous teleconferences to complete the work of the guideline.

Guidelines and Conflicts of Interest The expert panel complied with the IDSA policy on conflicts of interest, which requires disclosure of any financial or other interest that may be construed as constituting an actual, potential, or apparent conflict. Revision Dates At annual intervals, the panel chair, the SPGC liaison advisor, and the chair of the SPGC will determine the need for revisions to the guideline based on an examination of current literature.

Evidence Summary Preauthorization is a strategy to improve antibiotic use by requiring clinicians to get approval for certain antibiotics before they are prescribed. Table 1. Evidence Summary Implementation of facility-specific clinical practice guidelines can lead to substantial changes in antibiotic use for infections commonly treated in hospitals. Objective: To summarize ASP tactics that can improve the appropriate use of antimicrobials in the hospital setting.

Several measures can be used to implement such programs and gain multidisciplinary support while addressing common barriers.

Summary: Implementation of an ASP requires a multidisciplinary approach with an infectious diseases physician and a clinical pharmacist with infectious diseases training as its core team members. As identified by recently published guidelines, 2 proactive strategies for promoting antimicrobial stewardship include: 1 formulary restriction and pre-authorization, and 2 prospective audit with intervention and feedback.