Understanding Antimicrobial Stewardship and Applications in Healthcare

September 20, 2022 - Antimicrobial stewardship is a plan to improve antibiotic use and prescription. Many organizations, such as Children's Hospital Colorado, are working to enhance antimicrobial stewardship practices. Michael Bozzella, DO, infectious diseases attending physician at Children’s Hospital Colorado and professor of pediatrics at the University of Colorado, sat down with PharmaNewsIntelligence to discuss antimicrobial stewardship, how to implement it, and its applications across multiple healthcare landscapes.

Significance and Impacts

Antimicrobial resistance has universal impacts on all patient populations. While the Children’s Hospital Colorado (CHC) focuses predominantly on monitoring antibiotic use and resistance in pediatric populations, these issues impact adults and public health.

In his discussion with PharmaNewsIntelligence, Bozzella explained the effects on two patient populations: pediatric patients and immunosuppressed patients.

Pediatric Patient Impacts

Being a pediatrician by trade, Bozzella said, “sometimes I feel like our pediatric population is overlooked. The same reactions or issues that adults have happen in children as well. The more we learn about our microbiome every day, the real disruption caused by our antibiotics can have lifelong implications.”

Bozzella explains that disruptions can impact the health of pediatric patients whose microbiome is still developing. He explains, "those same issues that we have with adults — kidney injury, hepatotoxicity, the risks associated with having a PICC line — are all associated with increased risks of infection.”

Throughout the conversation, Bozzella emphasized that antimicrobial stewardship is essential across all ages and backgrounds.

Immunocompromised Patient Impacts 

PharmaNewsIntelligence asked Bozzella about the potential impacts of antimicrobial stewardship on immunocompromised populations. He shared that, for immunocompromised patients, stewardship programs are even more critical.

“If clinicians continue to overuse antibiotics, we're going to see increasing rates of those more resistant bacteria, such as ESBL bacteria. Again, like those gram-negative bugs, Klebsiella, Pseudomonas, and E. coli, just in our environment. So, if a patient has a compromised immune system, they’re going to be that much more likely to pick these up in an environment that's much more ill,” noted Bozzella.

Environmental Impacts 

Beyond individual patient impacts, antimicrobial stewardship programs can prevent global antibiotic resistance and improve public health overall. As previously mentioned, an optimized antibiotic prescription will reduce the prevalence of resistant bacteria and, in turn, their spread.

“Decreasing the overuse of antibiotics also decreases the rates of resistance in the environment that patients could be exposed to. So, it benefits both sides of things,” said Bozzella.

Implementing Antimicrobial Stewardship

Implementing antimicrobial stewardship is a complex process that requires a multifaceted approach. Bozzella told PharmaNewsIntelligence that the method is not one size fits all.

“It's hard to apply one be-all-end-all strategy to every hospital. In working with some of these smaller hospitals, clinicians researching antimicrobial stewardship found that it's really those tailor-made approaches. At the heart of everything, it's always adhering to those CDC core elements of antimicrobial stewardship, and really what it boils down to is having time, interest, and the capacity,” began Bozzella.

The approaches vary based on the healthcare environment and team. “For example, here at Colorado Children's, we use a handshake approach, which I find helps establish those relationships. It helps us be seen as people who are there to help find the best outcomes for our patients.”

Stewardship Team

The team heading the approach is a big part of successful antimicrobial stewardship across all hospital settings. Bozzella said, “the best world is having a physician and a pharmacist who can work together and have the dedicated time and support to pursue antimicrobial stewardship programs.”

Laying the Groundwork

Beyond recruiting and empowering a stewardship team, hospitals and facilities looking to implement stewardship must consider the importance of data collection.

Bozzella told PharmaNewsIntelligence that “another piece of laying the groundwork is to have, especially in those larger hospitals, a system or a tool, or reports, built into the electronic medical record.”

Bozzella explains that these reports can be run daily or every few days to determine the antibiotic prescription rate. At that point, clinicians can point out prescription rate issues or the prescription's primary causes.

Addressing Antibiotic Misconceptions from a Provider Standpoint

There are many common misconceptions that clinicians encounter when it comes to antibiotics. In a pediatric setting especially, many parents will bring their child in for treatment and expect an antibiotic for treatment when they may not be necessary.

Bozzella points out that antibiotic utilization in an outpatient setting is an area in desperate need of antimicrobial stewardship. He explains that many parents have preconceived notions about antibiotics that need to be addressed.

In his explanation, Bozzella explains that the solution to this issue is two-fold, but both aspects focus on educational efforts. First, public health campaigns must work to share additional information. Second, providers play a role in educating parents about antibiotics and antibiotic resistance.

From a public health perspective, “programs like what's coming out with the CDC, the Be SMART campaign, are great ways to start spreading the word and out into the public about that prime difference. Antibiotics only treat bacteria. Most infections come from viruses.”

On a provider level, Bozzella suggests adding informational posters and graphics to areas that patients and parents frequent, such as waiting and patient rooms. Additionally, Bozzella recommends that provider sign and distribute commitment letters to their patients stating and justifying why they will not prescribe antibiotics or viral infections.

“It must be a multi-pronged approach, working both the larger public health level through the CDC to get these advertisements or infographics out there and on the individual provider level to really re-empower them,“ Bozzella advised.

Financial Benefits of Antimicrobial Stewardship

Beyond the clinical changes and beneficial outcomes, there is also a significant financial benefit to antimicrobial stewardship programs. Bozzella shared that, in a retrospective analysis done by his colleagues, the cost savings amounted to $2 million.

A large chunk of these savings comes from reduced antibiotic prescriptions. However, Bozzella also shares that there are “fewer instances of hospital readmission for adverse reactions or outcomes related to antibiotic overuse. Especially on the adult side, rates of Clostridioides difficile dramatically drop. And that saves readmissions, medical stays, and the cost associated with those.”

Future Directions

The hope is that projects, such as the one Bozzella is a part of, will help improve and optimize the utilization of antibiotics. Additional goals include minimizing antibiotic resistance, improving antibiotic education, and enhancing patient outcomes.

“Medicine is a collaborative sport. Every day, we learn more. At the end of the day, antimicrobial stewards are not here to be antibiotic police by any means. They are just here to help,” concluded Bozzella