What is antibiotic stewardship? How you can practice it

You’ve got a bad cough, stuffy nose, and sore throat. You visit your healthcare provider and ask for antibiotics. Your primary care provider declines to give you a prescription and explains that you have a virus. Meaning, the best treatment is rest, fluids, and some OTC meds. What gives? This is an example of good antibiotic stewardship. 

If what you have is truly viral, then antibiotics won’t work—they’re only for bacterial infections. You might leave your healthcare provider’s office frustrated that you’re stuck with a prescription to sleep and hydrate instead of one for amoxicillin. But, by trusting your clinician’s judgment, you’re practicing good antibiotic stewardship, too.

It’s important because the inappropriate use of antibiotics can lead to a host of problems for healthcare providers and patients alike. Here’s the scoop on what antibiotic stewardship means and all the ways you can play a role in promoting it.

What does antibiotic stewardship mean? 

Antibiotic stewardship, sometimes also referred to as antimicrobial stewardship, is a joint effort by healthcare providers to embrace responsible prescribing of antibiotics. That includes prescribing antibiotics only when they are needed (i.e., for bacterial infections, not viral ones), prescribing the appropriate antibiotics for the diagnosed infection, and prescribing the right dose and duration of antibiotic treatment, among other things.

According to the Centers for Disease Control and Prevention (CDC), focusing on the responsible use of antibiotics:

• Improves treatment of bacterial infections
• Protects patients from unnecessary side effects
• Limits the kind of overuse that leads to antibiotic resistant bacteria or “superbugs”

“Prescribing doctors mean well—they want to fix people, and the short-term downside for most antibiotics is small since they are generally safe and inexpensive,” explains Houston Methodist infectious disease expert Richard Harris, MD.

The problem, says Dr. Harris, comes when most of the patients you are trying to “fix” don’t actually need the treatment you’re providing: “You want to make sure you’re not missing something, but you end up overtreating 50 [patients] for every one patient who actually needs to be treated.”

When did antibiotic stewardship start?

Because there is too much inpatient and outpatient use of antibiotics overall, stewardship programs have developed across the country to mitigate the widespread unnecessary prescribing of these drugs. It’s unclear exactly when these programs worked their way into nearly every major hospital and healthcare facility in the United States, but Dr. Harris says the initiative was long overdue (as of 2018, nearly 85% of hospitals nationwide were meeting CDC guidelines).

The Society for Healthcare Epidemiology of America (SHEA) is another organization that promotes antimicrobial stewardship programs, providing tools and resources to healthcare professionals for implementation in acute care hospitals and long-term care facilities across the country. By improving the use of antimicrobials, SHEA states that these programs enhance patient outcomes, reduce antimicrobial resistance, and decrease healthcare-associated infections among other quality improvements. 

Kathryn A. Boling, MD, a primary care provider with Mercy Medical Center in Baltimore, agrees, calling the shift in focus onto antibiotic use a gradual change in response to the rise in resistant organisms, an increasing need to use powerful, intravenous antibiotics instead of common oral ones, and other environmental factors.

“People are flushing their antibiotics down the toilet or urinating out small amounts of these drugs, and it’s contaminating the water we drink,” she says. “[All those things together] were enough to make the medical community say ‘uh-oh.’”

In 2014, the CDC began rolling out specific guidelines and recommendations for how healthcare facilities, from hospitals to outpatient offices, could educate physicians and patients on the appropriate use of antibiotics through stewardship programs. 

3 types of antibiotic stewardship interventions

In The Core Elements of Hospital Antibiotic Stewardship Programs, the CDC laid out three main types of stewardship interventions that can improve the use of antibiotics: broad interventions, pharmacy-driven interventions, and specific interventions for infections and syndromes.

1. Broad interventions involve getting prior authorization to prescribe certain antibiotics, performing audits on cases involving antibiotics, and re-evaluating the antibiotics prescribed while diagnostic information is being collected. For example, you’re given ciprofloxacin in the emergency room for a suspected kidney infection while your blood work is sent to the lab; once your results come back, the prescribing physician revisits your info to see if that’s still the best antibiotic for you.
2. Pharmacy-driven interventions include adjusting doses of antibiotics, looking out for duplicate therapies and drug interactions, and assisting with transitions from IV to oral antibiotics.
3. Infection/syndrome specific interventions offer clear instructions for prescribers on using antibiotics to treat many infections with a history of antibiotic overuse, including: community-acquired pneumonia, urinary tract infections, skin and soft tissue infections, MRSA infections, Clostridium difficile infections (C. diff), and bloodstream infections that have been proven by culture.

If all three of these interventions are implemented, it follows that a hospital will see its antibiotic use data improve. But these interventions aren’t achieved by simply waving a magic wand. Hospitals have to invest in creating a solid antibiotic stewardship program based on several core elements outlined by the CDC. These elements work a little differently in other healthcare settings, but generally remain the same whether the stewardship program is taking place at inpatient or outpatient facilities.

Element	Hospital	Nursing Home	Outpatient Setting
Leadership	Commit to providing human, financial, and technical resources	Commit to improving antibiotic use and  communicating that commitment with staff, residents, and families	Appoint single leader and/or include stewardship in job descriptions
Accountability	One physician leader appointed	Engage medical director, nursing director, and other key staff in supporting efforts	Communicate widely with patients about efforts via flyers and face-to-face conversations
Drug expertise	One pharmacist leader appointed	Consult and partner with community experts in infectious disease	Provide clinicians with opportunities to consult with experts on or off-site
Action	Implement at least one intervention that can be regularly evaluated	Develop action plans to implement one or more of the three interventions	Use evidence-based prescribing, watchful waiting, and off-site triage for viral infections
Tracking	Keep track of prescribing and resistance patterns	Track antibiotic use and outcome measures	Self-evaluate and adopt at least one tracking/reporting system
Reporting	All relevant staff are informed of progress	none	Self-evaluate and adopt at least one tracking/reporting system
Education	All relevant staff are trained on responsible prescribing	Use flyers, guides, emails, and workshops to educate all staff, residents and families	Educate patients with materials and in-person conversations; provide continuing education opportunities for physicians

Why it’s important

The benefits of antibiotic stewardship programs, beyond the obvious reduction in the overuse of these drugs, apply to both individuals and the community at large, says Dr. Boling.

For individual patients, misusing antibiotics may mean you:

• Have a harder time getting rid of the infection if it returns
• Become sick with an antibiotic-resistant infection that can’t easily be treated
• End up with mild to severe antibiotic side effects, ranging from nausea and diarrhea to yeast infections, anaphylaxis, kidney failure, or infection with C. diff (a bacteria that causes persistent diarrhea and colon inflammation)

On a broader, public health level, incorrectly prescribing antibiotics:

• Increases antibiotic resistance and C. difficile infections overall
• Raises healthcare costs
• Lowers patient safety outcomes
• Leaves everyone vulnerable to those nasty superbugs

The more hospitals and outpatient care settings that adopt antibiotic stewardship programs, the more impact the collective efforts will have. The only tricky thing is evaluating the effectiveness of these programs. Drs. Boling and Harris both say that as of right now, there isn’t an official way to see if efforts are working. If a hospital can report a reduction in antibiotic use—or a reduction in adverse events as a result of using antibiotics—that’s considered a win. 

Dr. Boling adds that physicians practicing good antibiotic stewardship can also self-evaluate: “As an individual physician, you can look at your own personal metric. I can usually tell [the difference between a viral and bacterial infection] with my exam, but if I have a patient insisting something more is going on, I order a chest X-ray to confirm. Very rarely does that patient actually need antibiotics.”

How patients and providers can work together

If you’re wondering how you can do your part to limit antibiotic prescribing, it’s easier than you may think. 

1. Don’t make an appointment for every little thing. “Patients can stop asking for antibiotics the minute they get the sniffles,” says Dr. Boling. “If you don’t have a fever or the illness hasn’t been going on for 10 days or more, the chances are low you need antibiotics.”
2. Don’t call your healthcare provider’s office and ask staff to call in a prescription without an exam. Many illnesses associated with antibiotic overuse, like urinary tract infections, should be diagnosed with a culture before a prescription is written.
3. Trust your primary care provider. Dr. Harris says that if more people relied on their doctor’s judgment, resisting the urge to be disappointed when their doctor says their illness is only viral, doctors would feel less pressured to treat their patients unnecessarily with antibiotics.
4. Stay up to date on your vaccinations. “In my years of practice, the most beneficial thing that helps patients with infectious disease is vaccines,” says Dr. Harris. The fewer viral infections you get, the less likely you’ll be to seek out antibiotics when you’re not feeling well, lowering your chances of receiving a prescription you don’t really need.

One more thing: Every November, the World Health Organization (WHO) celebrates Antibiotic Awareness Week, encouraging all healthcare facilities, providers, and the general public to increase their education about the power of antibiotics—and how, if that power isn’t wielded correctly, it can lead to widespread consequences.

In 2020, Antibiotic Awareness Week will be celebrated from Nov. 11 to 17. Visit the WHO website to learn more about how you can practice it in your home, doctor’s office, hospital, or community.