FAQ: Antimicrobial Resistance & Antimicrobial Use

• Should health care facilities be changing their approach to antibiotic use?
• How can health care facilities improve their use of antibiotics?

This document has been prepared for educational purposes by:
Mark Loeb, M.D., MSc.
Microbiologist, Infectious Disease Consultant
Hamilton Health Sciences Corporation.

Should you have questions regarding individual health concerns or health care practices, please consult your physician or health care provider directly.

» Should health care facilities be changing their approach to antibiotic use?

Given the rapid emergence of bacterial resistance in health care facilities, especially hospitals, optimizing antibiotic use is an important concern. Excessive and inappropriate use of antibiotics may not only render commonly used antibiotics ineffective, but may also lead to an avoidable increase in side effects as well as cost. It is extremely important that institutions critically evaluate how and when antibiotics are used, and ensure that the best choices are made by individual prescribers.

» How can health care facilities improve their use of antibiotics?

A number of strategies exist to help health care facilities deal with this problem:

• Establish an antimicrobial sub-committee.
  Such a committee should be multi-disciplinary, including broad representation across facility programs. In a hospital setting, this committee optimally should include a microbiologist, an infectious disease physician, a pharmacist, physician representative(s) from surgery, an administrator, an infection control practitioner, and a representative from nursing. By meeting regularly (at least quarterly for most hospitals), the committee can set priorities for optimal antibiotic use and can monitor progress. Decisions about introducing new antibiotics into the hospital formulary and devising strategies to optimize antibiotic use should be made through this committee. Historically, less attention has been paid to antimicrobial utilization in facilities providing long-term care such as nursing homes and chronic care facilities. However, this is changing and the appropriate stakeholders for individual institutions need to be incorporated into the committee structure in these types of facilities. Since these facilities are less likely to have the diversity of expertise needed on site, consulting with external experts is critical.
  
• Introduce strategies to influence physician prescribing habits
  Although changing physician prescribing patterns is notoriously difficult, educational interventions aimed at optimizing antibiotic use are nevertheless important. Educational sessions should be targeted firstly at "problem users" if such individuals/groups have in fact been identified. Persuasive methods however need to be supplemented by restrictive policies. Policy decisions should be made by the antimicrobial sub-committee and should be hospital specific. Potential strategies include restricting the antibiotic formulary, using automatic stop dates for antibiotics (e.g., regardless of the duration of the prescription, the antibiotic needs to be re-ordered after four days), in-house drug profiling , and using automatic antibiotic substitutions. Mandatory approval by the pharmacist or infectious disease physician, or mandatory consultation by a clinical pharmacist or infectious disease physician may also be effective in deterring the overuse of specific antimicrobials.
  
• Evaluate high use areas or indications
  In some hospitals, antibiotics for surgical prophylaxis can account for a considerable proportion of the antibiotics used. Since surgical records are usually readily available, assessing the appropriateness of such antibiotics can be done efficiently and monitored periodically. The use of standardized order forms can be effective at reducing inappropriate prescribing. In long term care facilities, the bulk of antimicrobials may be used to treat urinary tract infections and/or asymptomatic bacteriuria. This could be an area to target on for evaluation.
  
• Monitor results of intervention strategies
  Regardless of the exact strategies chosen, monitoring outcomes is key. The outcomes chosen may vary for different objectives, but they at least need to be relevant, easily available, and obtained in a standardized manner. For example, if automatic consults by a clinical pharmacist are introduced to reduce the use of a particular antibiotic in the intensive care unit, then monitoring the amount of antibiotic per 1000 ICU patient days prescribed would be reasonable. If standardized order forms for pre-operative orthopedic surgical prophylaxis are introduced, then monitoring the proportion of appropriate prescriptions (i.e. compliance with the order forms) is essential.

  Although optimizing antibiotic use in health care facilities is a challenge, the establishment of an antimicrobial sub-committee and the systematic monitoring of outcomes following interventions offer the best chance for success.