The State of Antimicrobial Stewardship

Segment Description: Jason Gallagher, PharmD, FCCP, FIDSA, BCPS, clinical professor at Temple University College of Pharmacy and editor-in-chief of Contagion®, describes the current state of antimicrobial stewardship efforts.

Interview Transcript (modified slightly for readability):

Gallagher: The state of antimicrobial stewardship is an interesting one, because as it has expanded and become a requirement, in now multiple different settings, not just in the hospital but long term care, there's now a push towards expanding it in outpatient settings, which is a logical push, because that's where the majority of non-animal antibiotic use is, the majority of human antibiotic use.

So, it's been interesting to see its uptake. One of the things we've seen is that inside hospitals many institutions are expanding their programs beyond just the first clinician that they once had, and hiring multiple pharmacists and multiple physicians at times to run those stewardship programs and sort of increase their impact.

One of the issues with it is as it has expanded from hospital to hospital, that the economic incentive to do stewardship sometimes becomes the dominant one. And I think that's unfortunate, and really not what it's supposed to be about.

Stewardship programs are a systematic way of optimizing antimicrobial therapy for each patient. And sometimes that's expensive, and sometimes it's cheap. Those programs on the whole tend to save money. That's good. But having that as the sole focus, I think, is a mistake.

In terms of the practices that drive overuse of antibiotics, there's a few classic ones, one of which is asymptomatic bacteriuria, which by definition should almost never be treated except in certain particular populations. And where that drives overuse is in nursing homes and certainly the hospital setting. But that nursing home one, we who work in inpatient settings don't think about nearly as frequently and is also one of the settings where ordering a test that you don't need leads to treating something that doesn't need to be treated pretty frequently.

Even though new guidelines that came out this year for community acquired pneumonia helped to kill off HCAP [Health care-associated pneumonia], we're still dealing with the consequences of that being an entity that was recommended to treat before where patients who, in years past would have received a little more narrow spectrum agent, are receiving broad spectrum therapy with things like vancomycin and PIP TAZO [piperacillin/tazobactam] because they have some risk factor for resistance that is a pretty minor risk factor in the grand scheme of things.

While that change in guidelines is going to be a plus, and it changed in the hospital acquired pneumonia guidelines several years ago, it always takes time for those things to trickle over into clinical practice.

And one more that is important is C diff. C diff is clearly an issue. And our diagnostics in one way have gotten much better in that they are more sensitive as people have switched to nucleic acid based assays from toxin based assays, and yet now they're so sensitive that they pick up people who have a positive gene or have a positive assay for a gene for C diff being present, but it's present not actually causing disease and that's now leading to overtreatment where we used to have the problem of undertreatment. This is something that the medical community is starting to figure out how to deal with.