GUIDELINES Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America Guidelines for Developing an Institutional Program to Enhance Antimicrobial Stewardship

Timothy H. Dellit, Robert C. Owens, John E. McGowan, Jr., Dale N. Gerding, Robert A. Weinstein, John P. Burke, W. Charles Huskins, David L. Paterson, Neil O. Fishman, Christopher F. Carpenter, P. J. Brennan, Marianne Billeter, and Thomas M. Hooton Harborview Medical Center and the University of Washington, Seattle; Maine Medical Center, Portland; Emory University, Atlanta, Georgia; Hines Veterans Affairs Hospital and Loyola University Stritch School of Medicine, Hines, and Stroger (Cook County) Hospital and Rush University Medical Center, Chicago, Illinois; University of Utah, Salt Lake City; Mayo Clinic College of Medicine, Rochester, Minnesota; University of Pittsburgh Medical Center, Pittsburgh, and University of Pennsylvania, Philadelphia, Pennsylvania; William Beaumont Hospital, Royal Oak, Michigan; Ochsner Health System, New Orleans, Louisiana; and University of Miami, Miami, Florida

T he Infectious Diseases Society of America (IDSA) and the Society for Healthcare Epidemiology of America (SHEA) recently published guidelines for developing an institutional program to enhance antimicrobial stewardship. 1 These guidelines provide hospitals with another tool to combat antimicrobial resistance as part of their patient safety and quality assurance initiatives, recognizing that antimicrobial resistance results in increased morbidity, mortality, and cost of health care. A summary of the guideline is provided, with recommendations rated on the basis of the strength of the recommendation and the quality of evidence (Table 1) as given in the guideline.
Antimicrobial stewardship includes the appropriate selection, dosing, route, and duration of antimicrobial therapy. The primary goal of antimicrobial stewardship is to optimize clinical outcomes while minimizing unintended consequences of antimicrobial use, including toxicity, the selection of pathogenic organisms (such as Clostridium difficile), and the emergence of resistance. Thus, the appropriate use of antimicrobials is an essential component of patient safety and deserves careful oversight and guidance. The combination of effective antimicrobial stewardship with a comprehensive infection control has been shown to limit the emergence and transmission of antimicrobial-resistant bacteria. A secondary goal is to reduce health care costs without adversely impacting quality of care.
Effective antimicrobial stewardship programs, also known as antimicrobial management programs, require a multidisciplinary team approach. Core members include an infectious diseases physician and a clinical pharmacist with infectious diseases training (A-II), with the inclusion of a clinical microbiologist, an information system specialist, an infection control professional, and a hospital epidemiologist being optimal (A-III). Collaboration between the antimicrobial stewardship team and the hospital infection control and pharmacy and therapeutics committees is essential (A-III).
Two proactive core strategies have typically formed the foundation of successful antimicrobial stewardship programs, and these strategies are not mutually exclusive. The first is prospective audit of antimicrobial use with direct interaction and feedback to the prescriber, performed either by an infectious diseases physician or clinical pharmacist with infectious diseases training (A-I). The second core strategy involves formulary restriction and preauthorization requirements that can lead to significant and immediate reductions in antimicrobial use and cost (A-II). The longterm impact of preauthorization programs on antimicrobial resistance is less clear, and in some circumstances, use may simply shift to an alternative agent with resulting increased resistance. Depending on local antimicrobial use and resistance problems and on available resources that may differ depending on the size of the institution, the core active strategies may be supplemented by education (A-III), guidelines and clinical pathways (A-I), optimization of antimicrobial dosing (A-II), and a systematic plan for conversion from parenteral to oral therapy (A-I). Routine combination therapy has not been demonstrated to prevent the emergence of antimicrobial resistance (C-II); however, combination therapy does have a role in certain clinical contexts, including use of empiric therapy in critically ill patients at risk for infection with multidrug-resistant pathogens to increase the likelihood of adequate initial therapy (A-II). Empiric therapy should then be de-escalated based on culture results to target the causative pathogen (A-II). There is currently insufficient data to recommend the routine use of antimicrobial cycling as a means of preventing or reducing antimicrobial resistance (C-II).
Continued development of health care information technology in the form of electronic medical records (A-III), computer physician order entry (B-II), and clinical decision support (B-II) has the potential to improve antimicrobial decisions through the incorporation of data on patientspecific microbiology cultures and susceptibilities, hepatic and renal function, drug-drug interactions, allergies, and cost. Similarly, computer-based surveillance can facilitate good stewardship by more efficient targeting of antimicrobial interventions, tracking of antimicrobial resistance patterns, and identification of health care -associated infections and adverse drug events (B-II). However, implementation of these features has been slow. The support and collaboration of hospital administration, medical staff leadership, and local providers in the development and maintenance of antimicrobial stewardship programs is essential to the success of the program (A-III). Hospital administrations must appropriately resource these programs and provide compensation for the infectious diseases physician and clinical pharmacist (A-III), recognizing that this is money well spent. Effective antimicrobial stewardship programs are financially self-supporting and improve patient care. Comprehensive programs have consistently demonstrated a decrease in antimicrobial use (22% -36%), with annual savings of $150,000 to $900,000 in both larger academic hospitals and smaller community hospitals. For example, a review by an infectious diseases physician and clinical pharmacist 3 days per week of patients receiving multiple, prolonged, or high-cost courses of antimicrobial therapy resulted in an annual savings of $177,000 in a small 120-bed community hospital. 2 As an antimicrobial stewardship program is developed, process and outcome measures must be established to determine the impact on antimicrobial use, resistance patterns, and patient care (B-III). This information should be fed back to providers and hospital administration to create an ongoing dialogue around antimicrobial use and resistance.

Clinical Guidelines
These guidelines for the development of antimicrobial stewardship programs come at a critical time as antimicrobial resistance is also gaining attention in the general public and among policy makers with increasing focus and movement toward mandatory reporting of health care -associated infections. In addition, hospitals are being graded on a number of quality indicators that directly involve antimicrobial use including the Centers for Medicare & Medicaid Services and Joint Commission on Accreditation of Healthcare Organizations ORYX measures around surgical infection prevention 3 and community-acquired pneumonia. These measures are currently in the pay for participation period, with pay for performance looming in the near future. Finally, as outlined in the IDSA ''Bad Bugs, No Drugs'' campaign, 4 ensuring the continued availability of current and novel antimicrobials to combat existing and emerging resistant pathogens is a critical public health issue. Given the paucity of new antimicrobials in development, we must optimize our use of existing agents through effective antimicrobial stewardship.

ACKNOWLEDGMENTS
The author thanks the IDSA Antimicrobial Stewardship Guideline Committee and SHEA in the development of this guideline. In addition, the multidisciplinary importance of antimicrobial stewardship led to the collaborative review and support of these recommendations by the following organizations: American Academy of Pediatrics, American Society of Health-System Pharmacists, Infectious Diseases Society for Obstetrics and Gynecology, Pediatric Infectious Disease Society, Society for Hospital Medicine, and Society of Infectious Diseases Pharmacists.