Antimicrobial stewardship (AMS) is the activity of reviewing antimicrobial use and making sure it is appropriate. AMS aims to optimise prescribing practice at both the individual patient and population level. AMS is relevant to all clinical settings within a hospital as well as across primary care. AMS takes elements from a range of disciplines including microbiology, pharmacology, pharmacy, behavioural science, education, economics and quality management, and applies them in a blended and coordinated way to support, measure and drive improvements in antimicrobial prescribing.
The main motivation for AMS is the increasing and alarming level of antimicrobial resistance (AMR) around the world, strongly driven by heavy use of antimicrobials in healthcare settings. There is widespread acknowledgement that much clinical use of antimicrobials is inappropriate. AMS aims to reduce inappropriate antimicrobial use in order to maintain the effectiveness of these drugs. While the main focus currently of AMS is to prevent antimicrobial resistance, AMS was initially developed as a way of tackling the burgeoning costs of antimicrobials. In addition, AMS aims to ensure optimum clinical outcomes and minimise patient adverse effects including drug-related organ toxicities and ecological harm such as Clostridioides difficile diarrhoeal disease. These demands still form part of the brief of AMS teams who are required to navigate a policy course around what may be competing aims.
AMS is typically a multi-disciplinary team activity, undertaken by medically qualified infection specialists including medical microbiologists and/or infectious diseases physicians depending on local practice pharmacists with training in antimicrobials, data analysts and secretarial/ administrative support. The AMS team works with clinicians involved in the prescription, dispensing and administration of antimicrobials to raise and maintain standards of antimicrobial use.
AMS can be implemented in a number of ways. At its most basic, AMS teams provide prescribers with guidelines to support prescribing choices for frequently encountered infections. These guidelines may provide empirical choices for initial treatment prior to microbiological confirmation of the identity and antimicrobial susceptibility of the infecting organism. Guidelines for the use of antimicrobials to prevent infections, for example, surgical site infections, are another basic AMS undertaking. The basis of the guidelines is best based on local pathogen antimicrobial susceptibility data, but if local data is not available, then susceptibility patterns will have to be assumed.
The next level of AMS activity is the measurement of antimicrobial use and compliance with guidelines. This activity is based on data that may have to be collected manually from prescribing records, but which is more readily undertaken when the AMS team has access to digital patient and prescribing records. The AMS team is then able to carry out analysis of antimicrobial prescribing practice at levels ranging from individual prescribers to the whole healthcare organisation and provide feedback with suggestions for improvement.
The most comprehensive approach to AMS sees antimicrobial prescribing as a pathway that includes diagnosis, antimicrobial prescribing, administration of the drug and review of the effect of treatment (figure 1). Each of the pathway stages depends on the preceding steps and defects in performance at any point can lead to ineffective treatment, patient harm, unnecessary healthcare costs and the promotion of resistance. The prescribing process is a complex one and maintaining a consistently high quality of care requires the application of quality management system (QMS) methods – quality planning (determining what factors are important to deliver effective treatment), quality control (defect detection), quality assurance (defect prevention) and quality improvement (driving up quality).
Figure 1: An outline of the infection antimicrobial management pathway
While these activities make up the core of AMS, the ability to carry out quality stewardship depends on the availability of adequate resources (trained personnel with time allocated to AMS, information and analysis systems) and an organisational culture that values and supports AMS activities. Variation in any of these elements is likely to affect the effectiveness of AMS.
Standards and accreditation
The need for accreditation of AMS practice is clear. AMS research has identified effective approaches to controlling and optimising antimicrobial prescribing but there is patchy adoption of these approaches within and between countries. Consequently, the benefits of AMS are not being fully realised. Accreditation of AMS practice, using evidence-based standards, offers several opportunities.
The process of preparing for and undergoing accreditation, when supported by access to educational material and expert help, can aid healthcare organisations identify areas for improvement and prioritise remedial actions. Healthcare payers (governments, insurers, patients) can use the outcome of accreditation to identify good quality healthcare providers and use the information to ensure that they are buying effective care.
While whole hospital accreditation schemes and those focused on Infection Prevention and Control are likely to include an element that addresses AMS, accreditation assessments of many different departments and services may lose sight of weaknesses in AMS practice and AMS will not figure prominently in final reports or priorities for action.
Consequently, an accreditation programme that has as its sole focus the quality of AMS activities will be able to highlight areas that need improvement or resourcing. Standards for hospital AMS programmes have been developed in the United States (CDC,2019) focused on core elements and and in Australia focused on AMS related to Infection prevention and clinical care elements (NSQHS 2019, 2020). Checklists for AMS programmes have also been developed in the UK to support local and global AMS (NICE 2015; CPA 2020).
BSAC Global Antimicrobial Stewardship Accreditation Programme (GAMSAS)
The BSAC GAMSAS scheme builds on existing published standards and checklists to support AMS activity through the development of standards that meet RUMBA criteria (Realistic, Understandable, Measurable, Behavioural, Achievable), including sensitivity to the range of resources available in different countries and healthcare settings. Standards will include elements that probe the structure of hospital characteristics, organization and institutional support of ABS program, hospital resources, and ABS activities. These standards will contribute to the authority and appeal of GAMSAS as an accreditation programme, supplemented with scrupulous attention to governance, including fair and transparent assessment processes, and the provision of education and training support as required.
It is intended that GAMSAS will issue a points-based report to candidate organisations that will identify progress along a pathway to best AMS practice, allowing them to know what actions are needed to improve. As the number of inspected organisations increases, the accreditation reports will provide an overview of the state of AMS practice nationally and regionally, identifying recurrent themes that need attention and adding additional value to the GAMSAS programme.
Opportunities for research
GAMSAS offers a range of opportunities for research using both quantitative and qualitative methods. A crucial question to address is how effective is accreditation in improving the quality of antimicrobial prescribing, including appropriateness of antimicrobial choice, dose, route and duration. Understanding attitudes of clinicians to the need for AMS would also be valuable, especially if these attitudes are barriers to good prescribing. Identification of factors that place limits on AMS practice is also a priority. These and other questions have a practical value because they will determine how best to support a sustainable accreditation programme, and feed into policy decisions on healthcare resource allocations.