Antimicrobial stewardship: concepts and strategies in the 21st century

Large worldwide surveillance studies report that resistance to nearly all classes of antimicrobial is increasing, as is the emergence of what have been termed pan-drug–resistant and extremely drug-resistant pathogens. Concomitantly, bacterial binding sites have been exploited by available antimicrobials, and there has been a decline in the development of antimicrobials using novel mechanisms of action. These trends have prompted healthcare facilities to adopt antimicrobial stewardship programs (ASPs) and infection control programs (ICPs) to monitor antimicrobial use while simultaneously optimizing treatment, outcome, and cost. This article outlines the development of an effective ASP and the key components and operating principles, and also provides insight into the production of materials that will facilitate the execution of these programs at healthcare facilities. In this discussion, education of healthcare providers is emphasized, and a rationale is provided with regard to the health, safety, and financial benefits that can be obtained from an ASP. A brief history of antimicrobial stewardship is included, providing the context for several studies of antimicrobial stewardship practice, which are also reviewed. Programs for optimal use are illustrated, including a prospective audit and feedback strategy and preauthorization procedure. The components of an effective ASP are described in depth, drawing examples from the literature, as well as from the author's personal experience at the Maine Medical Center, Portland, ME.