Antimicrobial stewardship and the need for metrics
Posted on 10th August 2022 by Jehath Syed
The discovery of antibiotics
The ancient western medical world has utilized bloodletting, leeches, and knives to manage infectious diseases. In the early 20th century, infectious diseases such as smallpox, cholera, diphtheria, and typhoid fever, accounted for high morbidity and mortality worldwide with an average life expectancy at birth of 47 years. However, with the first antibiotic introduced in 1910, Salvarsan, and consequent research in antibiotics, this has dramatically changed modern medicine, adding 23 years to the average life expectancy of a human.
The discovery of penicillin in 1928 by Sir Alexander Fleming marked the start of the antibiotics revolution. In 1942, Ernst Chain and Howard Florey were successful in purifying the first Penicillin, and Penicillin G. This marked the beginning of the new age of antibiotics. This era of antibiotics witnessed the discovery of many more antibiotics, with the period between the 1950s and 1970s being called the ‘golden age’ of new antibiotics. Dramatically, the leading causes of death have changed from communicable diseases to non-communicable diseases (cardiovascular disease, cancer, and stroke), and the average life expectancy at birth rose to 78.8 years, and older population changed from 4% to 13% in the USA alone.
The emergence and challenge of antimicrobial resistance
However, although the discovery of antibiotics has revolutionised the treatment of infectious diseases by lowering the mortality and morbidity among individuals, a major threat to the achievements of the antibiotic era is antibiotic resistance, which is the ability of bacteria to resist the effects of the antibiotic to which they were originally sensitive. Therefore, prescribing antibiotics requires careful consideration and detailed laboratory studies before initiating the therapy and yet antibiotics are among the most prescribed medications in hospitalised patients. Antibiotic overuse and misuse in terms of wrong medication, dose, frequency, duration of therapy or indication, has resulted in a rapid rise in the antimicrobial resistant bacteria, side effects, drug interactions, increased length of hospital stay, and increased costs which is expected to cause at least 2 million illnesses and 23,000 deaths annually.
The World Health Organization (WHO) has named antimicrobial resistance as one of the top ten global public health problems. Further, the Global Antimicrobial Resistance and Use Surveillance System (GLASS) 2020 report states that there are more than three million laboratory confirmed infectious illness cases, as well as their resistance patterns, indicating that resistance is far more prevalent in low- and middle-income countries.
In India alone, antibiotic resistance sepsis kills an estimated 56,254 newborns each year and, according to the ‘Scoping Report on Antimicrobial Resistance In India (2017)‘ published under the emblem of the Government of India, more than 70% of isolates of Escherichia coli, Klebsiella pneumoniae, and Acinetobacter baumannii, as well as nearly half of all Pseudomonas aeruginosa, were resistant to current fluoroquinolones and third generation cephalosporins. Colistin resistance has also emerged in India. Although the rate of colistin resistance was 1% (except for 4.1 percent reported by Gandra et al), colistin-resistant Klebsiella Pneumonia was associated with a 70% mortality rate. Methicillin resistance was found in 42.6 % of Staphylococcus aureus and 10.5% of Enterococcus facecium among the gram-positive organisms. Resistance rates for ciprofloxacin were 28 and 82 %, respectively, for Salmonella Typhi and Shigella species, 0.6 and 12% for ceftriaxone, and 2.3 and 80 % for co-trimoxazole. Tetracycline resistance rates in Vibrio cholera ranged from 17 to 75 % across India.
Furthermore, around 700,000 people are dying each year from antimicrobial resistance (AMR) and another ten million are projected to die by 2050. AMR alone is killing more people than cancer and traffic accidents combined. Economic projections indicate that by 2050, AMR will reduce global GDP by 2-3.5%, livestock losses of 3-8 %, and costing the world $100 trillion. The global rise of AMR has not just piqued the interest of the World Health Organization, but also many other stakeholders such as Government agencies, non-profit organisations, and patient-centred advocacies, which has resulted in WHO declaring AMR an urgent priority area. This has instigated several European leaders to develop action plans and road maps to combat AMR. India has also developed its AMR National Action Plan (NAP). The world is galvanised to make serious efforts to combat this common enemy, the antimicrobial resistance.
Antimicrobial stewardship and the need for metrics
Antimicrobial resistance has a negative impact on people and healthcare systems. This problem is exacerbated by a decline in the number of antimicrobial medicines approved over the last 25 years, with no obvious rebound in sight. The combination of rising antibiotic resistance and fewer new antibiotic approvals highlight the importance of judicial antimicrobial management. Many institutions are implementing antimicrobial stewardship programmes (ASPs) to raise awareness of the importance of antibiotic stewardship.
The Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA) guidelines encourage ASPs to improve patient outcomes not only by limiting their inappropriate use, but also by optimising antimicrobial selection and mitigating unintended consequences following antimicrobial use, such as resistance development and adverse drug events. The cost savings are a bonus. However, there is no consensus on the best outcomes and metrics for measuring the effectiveness of these programmes.ASPs are a multidisciplinary effort to improve the quality of antibiotic use, prevent antimicrobial resistance, ensure cost-effective therapy, and improve patient outcomes. The goal of the ASP is to assist clinicians in making the best therapeutic decisions possible regarding antimicrobial therapy initiation, spectrum of activity, adjustment, and withdrawal. A significant barrier to achieving these changes is the lack of established metrics for tracking the impact of ASPs on outcomes. Several experts have proposed quality metrics that are based on data from various sources, such as antibiotic consumption, process measures, and antibiotic resistance. Tracking and reporting antimicrobial use and outcomes is critical for assessing the ASP’s success and identifying areas for improvement.
Metrics that accurately reflect or forecast patient-focused outcomes are ideally suited to guide decision-makers and encourage improved behaviour. They should be simple to comprehend, straightforward to quantify, and important to patients and stakeholders alike. As a result, when developing ASP priorities and metrics, it is critical that quality-of-care indicators be linked to clinical results.
Multidisciplinary teams consisting of an infectious diseases physician, an infectious diseases clinical pharmacy specialist, a clinical microbiologist, an infection control professional, an information system specialist, and a hospital epidemiologist are excellent for ASPs in care institutions. These initiatives have been shown to have a positive impact on patient outcomes (e.g., fewer adverse medication events, CDI, morbidity and mortality, length of stay, antibiotic resistance, and improper prescribing) as well as healthcare costs. In long-term care facilities, the infection control and prevention nurse are usually in charge of AMS, ideally with the help of consultant pharmacists, nursing directors, and medical centre directors. Antimicrobial use that is appropriate attempts to improve patient outcomes and reduce multidrug resistance (MDR). The implementation of ASPs in accordance with the Centres for Disease Control and Prevention’s “Core Elements of Hospital Antibiotic Stewardship Programs” is a national goal (National Action Plan for Combating Antibiotic-Resistant Bacteria). Hospitals and long-term care institutions will be required to construct ASPs based on these elements by the Joint Commission and the Centers for Medicare and Medicaid Services in 2017. Two of the CDC’s major parts have to do with measuring and reporting ASP success.
For a variety of reasons including patient complexity, confounding factors, and measure selection that appropriately portrays the program’s impact, picking metrics to evaluate ASPs, their impact on patient outcomes, and the development of resistance, is difficult. There are guidelines on the most significant antimicrobial use and cost indicators. However, few measures for assessing antimicrobial use quality and clinical outcomes have been validated and included into routine programme evaluations. With healthcare reform and a shift away from fee-for-service to quality-of-care models, ASPs should re-focus their efforts on higher-level outcome indicators. The presence of confounding factors, the difficulty of attributing an improvement in outcomes directly to an ASP intervention, and the feasibility of extracting metrics, performing meaningful analyses, and translating results into actionable conclusions are all limitations to proposed outcome metrics.
Metrics that most accurately reflect or predict patient-focused outcomes are best suited to aid decision-makers and encourage improved behaviour. They should be simple to grasp, easy to measure, and meaningful to both patients and stakeholders. As a result, when developing ASP priorities and metrics, it is critical that quality-of-care indicators be linked to clinical outcomes.