Aims and Indicators for AS programs

Cèline Pulcini, Nice (France)


Antibiotic stewardship (ABS) programmes aim to optimise antimicrobial drug use. Promoting the appropriate use of antibiotics is intended to reduce emergence of resistance, decrease heath care costs and drug related adverse events while improving clinical outcomes. Numerous different stewardship activities can be implemented: audit and feedback, formulary restrictions, education, guideline development, de-escalation, nominative order forms, dose optimisation, IV to oral switch, computerised decision support, etc..

It is of utmost importance to plan from the start how to assess the implemented ASP programme. These practical tools will allow designing an effective programme, evaluating its impact and to further prioritising actions. Objective measurements will also demonstrate to the administrative and medical board that an ASP programme brings about changes.

There are a variety of measurements to evaluate stewardship programmes, which can broadly be grouped as structure, process or outcome measures. It is important to differentiate improvement from accountability measures; the former are embedded in clinical continuous quality improvement programmes whereas the latter is used for benchmarking.

  • Structure measures describe the organisation in place: personnel involved, dedicated time, availability of guidelines…
  • Process measures are ideally linked to improved outcomes in the literature; they describe, for example, adherence to guidelines, IV-oral switch, reassessment of antibiotic prescriptions around day 3, infectious diseases specialist’s advice for bacteraemias, timing of surgical antibiotic prophylaxis…
  • The outcome metrics measure the results achieved: antibiotic use, resistance rates, and incidence of C. difficile infections and of healthcare-associated infections…

Such structure and process indicators should be measured and improved using an audit and feedback strategy, leading hopefully to better outcomes.

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Most Relevant Articles on the Topic

Inpatient setting

Original articles

  • Schouten JA, Hulscher ME, Wollersheim H, Braspennning J, Kullberg BJ, van der Meer JW, Grol RP. Quality of antibiotic use for lower respiratory tract infections at hospitals: (how) can we measure it? Clin Infect Dis. 2005;41:450-60.
  • Zarb P, Ansari F, Muller A, Vankerckhoven V, Davey PG, Goossens H. Drug utilization 75% (DU75%) in 17 European hospitals (2000-2005): results from the ESAC-2 Hospital Care Sub Project. Curr Clin Pharmacol. 2011;6:62-70.
  • Buyle FM, Metz-Gercek S, Mechtler R, Kern WV, Robays H, Vogelaers D, Struelens MJ; Antibiotic Strategy International-ABS Quality Indicators Team. Prospective multicentre feasibility study of a quality of care indicator for intravenous to oral switch therapy with highly bioavailable antibiotics. J Antimicrob Chemother. 2012;67:2043-6.
  • Nathwani D, Sneddon J, Patton A, Malcolm W. Antimicrobial stewardship in Scotland: impact of a national programme. Antimicrob Resist Infect Control. 2012;1:7.
  • Malcolm W, Nathwani D, Davey P, Cromwell T, Patton A, Reilly J, Cairns S, Bennie M. From intermittent antibiotic point prevalence surveys to quality improvement: experience in Scottish hospitals. Antimicrob Resist Infect Control. 2013;2:3.

Review papers

  • Pulcini C, Crofts S, Campbell D, Davey P. Design, Measurement, and Evaluation of an Education Strategy in the Hospital Setting to Combat Antimicrobial Resistance: Theoretical Considerations and a Practical Example. Dis Manag Health Outcomes 2007;15:151-63.
  • Allerberger F, Lechner A, Wechsler-Fördös A, Gareis R. Optimization of antibiotic use in hospitals–antimicrobial stewardship and the EU project ABS international. Chemotherapy. 2008;54:260-7.
  • Marwick C, Davey P. Care bundles: the holy grail of infectious risk management in hospital? Curr Opin Infect Dis 2009; 22:364-9.
  • Nathwani D, Sneddon J, Malcolm W, Wiuff C, Patton A, Hurding S, Eastaway A, Seaton RA, Watson E, Gillies E, Davey P, Bennie M; Scottish Antimicrobial Prescribing Group. Scottish Antimicrobial Prescribing Group (SAPG): development and impact of the Scottish National Antimicrobial Stewardship Programme. Int J Antimicrob Agents. 2011;38:16-26.
  • Chung GW, Wu JE, Yeo CL, Chan D, Hsu LY. Antimicrobial stewardship: A review of prospective audit and feedback systems and an objective evaluation of outcomes. Virulence. 2013;4(2).


Outpatient setting

Original articles

  • Hansen MP, Bjerrum L, Gahrn-Hansen B, Jarbol DE. Quality indicators for diagnosis and treatment of respiratory tract infections in general practice: a modified Delphi study. Scand J Prim Health Care. 2010;28:4-11.
  • Coenen S, Ferech M, Haaijer-Ruskamp FM, Butler CC, Vander Stichele RH, Verheij TJ, Monnet DL, Little P, Goossens H; ESAC Project Group. European Surveillance of Antimicrobial Consumption (ESAC): quality indicators for outpatient antibiotic use in Europe. Qual Saf Health Care. 2007;16:440-5.
  • Adriaenssens N, Coenen S, Tonkin-Crine S, Verheij TJ, Little P, Goossens H; on behalf of the ESAC Project Group. European Surveillance of Antimicrobial Consumption (ESAC): disease-specific quality indicators for outpatient antibiotic prescribing. BMJ Qual Saf. 2011[Epub ahead of print]
  • Adriaenssens N, Coenen S, Versporten A, Muller A, Vankerckhoven V, Goossens H; ESAC Project Group. European Surveillance of Antimicrobial Consumption (ESAC): quality appraisal of antibiotic use in Europe. J Antimicrob Chemother. 2011;66 Suppl 6:vi71-77.
  • Pulcini C, Lions C, Ventelou B, Verger P. Drug-specific quality indicators assessing outpatient antibiotic use among French general practitioners. Eur J Public Health. 2012[Epub ahead of print]
  • Pulcini C, Lions C, Ventelou B, Verger P. Approaching the quality of antibiotic prescriptions in primary care using reimbursement data. Eur J Clin Microbiol Infect Dis. 2012[Epub ahead of print]
  • Pulcini C, Lions C, Ventelou B, Verger P. Indicators show differences in antibiotic use between general practitioners and paediatricians. Eur J Clin Microbiol Infect Dis. 2013[Epub ahead of print]


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