Oliver J Dyar, Kidlington (UK) and Cèline Pulcini, Nice (France)
Developing local guidelines and protocols is a key step in implementing antimicrobial stewardship programmes in a specific hospital or community setting. Combining relevant local microbiology data with stewardship prescribing principles (e.g. empirical therapy, de-escalation, defined treatment duration) helps ensure that patients get the most appropriate treatment whilst reducing drivers of antibiotic resistance. There is growing evidence that adherence to antimicrobial guidelines at an institutional level reduces mortality and morbidity, length of hospital stay, and antibiotic costs.
Guidelines usually focus on recommending specific empirical antibiotic choices for common types of infection (pneumonia, urinary tract infection, sepsis of unknown source…), often including suggestions for individuals with penicillin allergies, or renal/hepatic failure. Adoption of local guidelines may be improved in certain circumstances by considering how antimicrobial therapy fits in with other aspects of a patient’s clinical pathway, for example through the creation of ‘sepsis care bundles’ which provide a checklist of investigations and multiple management aspects. Guidelines for outpatient antibiotic may need to emphasise the specific indications for antibiotic use, as primary care doctors tend to have less access to microbiology advice.
The antibiotic selection content of guidelines can be created through integrating national antibiotic use guidance with the local pharmacy formulary and relevant microbiology resistance data. The ADAPTE framework can be used to minimise barriers to the development and acceptance of guidelines. In particular, guidelines must be evidence-based and developed by a multidisciplinary group, involving all key stakeholders to foster acceptance and ownership.
An important step in guideline development is investigating who the main prescribers are, and targeting educational and awareness interventions towards them. Use of local guidelines can be enhanced by involving the prescribers in the development of the guidelines, making the guidelines more accessible through creating multiple formats (electronic documents, paper-based), the physical location of guidelines, and ensuring design and access consistency with other guidelines used in your setting. Local guidelines and protocols can also facilitate the auditing process of antibiotic prescribing through creating a more clearly defined gold standard, and can integrate with infection prevention and control precautions.
References and Resources
- Price J, Ekleberry A, Grover A, Melendy S, Baddam K, McMahon J, Villalba M, Johnson M, Zervos MJ. Evaluation of clinical practice guidelines on outcome of infection in patients in the surgical intensive care unit. Crit Care Med. 1999 Oct;27(10):2118-24.
- Enoch DA, Phillimore N, Mlangeni DA, Salihu HM, Sismey A, Aliyu SH, Karas JA. Outcome for Gram-negative bacteraemia when following restrictive empirical antibiotic guidelines. QJM. 2011 May;104(5):411-9.
- 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 Jul;38(1):16-26.
- Carthey J, Walker S, Deelchand V, Vincent C, Griffiths WH. Breaking the rules: understanding non-compliance with policies and guidelines. BMJ. 2011 Sep 13;343:d5283.
- Gagliardi AR, Brouwers MC, Palda VA, Lemieux-Charles L, Grimshaw JM. How can we improve guideline use? A conceptual framework of implementability. Implement Sci. 2011 Mar 22;6:26.
- van der Velden LB, Tromp M, Bleeker-Rovers CP, Hulscher M, Kullberg BJ, Mouton JW, Sturm PD, Pickkers P. Non-adherence to antimicrobial treatment guidelines results in more broad-spectrum but not more appropriate therapy. Eur J Clin Microbiol Infect Dis. 2012 Jul;31(7):1561-8.
- Smith BP, Fox N, Fakhro A, LaChant M, Pathak AS, Ross SE, Seamon MJ. “SCIP”ping antibiotic prophylaxis guidelines in trauma: The consequences of noncompliance. J Trauma Acute Care Surg. 2012 Aug;73(2):452-6.
- Vazquez-Lago JM, Lopez-Vazquez P, López-Durán A, Taracido-Trunk M, Figueiras A. Attitudes of primary care physicians to the prescribing of antibiotics and antimicrobial resistance: a qualitative study from Spain. Fam Pract. 2012 Jun;29(3):352-60.
- Cabana MD, Rand CS, Powe NR, Wu AW, Wilson MH, Abboud PA, Rubin HR. Why don’t physicians follow clinical practice guidelines? A framework for improvement. JAMA. 1999 Oct 20;282(15):1458-65.
- Pagani L, Gyssens IC, Huttner B, Nathwani D, Harbarth S. Navigating the Web in search of resources on antimicrobial stewardship in health care institutions. Clin Infect Dis. 2009 Mar 1;48(5):626-32.
- Levy-Hara G, Amábile-Cuevas CF, Gould I, Hutchinson J, Abbo L, Saxynger L, Vlieghe E, Cardoso FL, Methar S, Kanj S, Ohmagari N, Harbarth S; International Society of Chemotherapy Antimicrobial Stewardship Working Group. “Ten Commandments” for the Appropriate use of Antibiotics by the Practicing Physician in an Outpatient Setting. Front Microbiol. 2011;2:230.
- Tamma PD, Cosgrove SE. Antimicrobial stewardship. Infect Dis Clin North Am. 2011 Mar;25(1):245-60.
- Teixeira Rodrigues A, Roque F, Falcão A, Figueiras A, Herdeiro MT. Understanding physician antibiotic prescribing behaviour: a systematic review of qualitative studies. Int J Antimicrob Agents. 2013 Mar;41(3):203-12.
- Dellit TH, Owens RC, McGowan JE Jr, et al; Infectious Diseases Society of America; Society for Healthcare Epidemiology of America. Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clin Infect Dis 2007;44:159-77.
- Department of Health Advisory Committee on Antimicrobial Resistance and Healthcare Associated Infection (ARHAI) ANTIMICROBIAL STEWARDSHIP: “START SMART – THEN FOCUS” 2011. Subsection 2.4.4