Prospective audit and feedback of antimicrobial stewardship in critical care: program implementation, experience, and challenges.

Antimicrobial stewardship has been defined as the limitation of inappropriate use of antimicrobials while optimizing the selection, dosing, route, and duration of antimicrobial therapy to maximize clinical cure or prevent infection; limiting unintended consequences, such as emergence of resistance, occurrence of adverse drug events, and selection of pathogenic organisms (such as Clostridium difficile); and minimizing cost. Because of increased resistance to antimicrobial agents and a lack of novel agents, there has been increasing pressure for judicious use of currently available antimicrobials, to ensure that their activity is preserved. In Canada, the need for anti microbial stewardship has been recognized as a patient safety issue by the Institute for Safe Medication Practices Canada, the Ontario Agency for Health Protection and Promotion, and the Ontario Ministry of Health and Long-Term Care, and together these agencies have launched the Ontario Antimicrobial Stewardship Project. Accreditation Canada has also proposed that it be a Required Organizational Practice for institutions to have a program to appropriately manage antimicrobial resources. However, despite the well-recognized need to institute antimicrobial stewardship programs, detailed descriptions of the steps taken and challenges encountered in implementing successful programs are lacking in the literature. The purpose of this article is to describe our experience with the development of an antimicrobial stewardship program at a university-affiliated teaching hospital. Sunnybrook Health Sciences Centre (SHSC) is a tertiary care teaching hospital with 700 acute care beds located in Toronto, Ontario. Before 2007, this institution had an infectious diseases team (consisting of infectious diseases physicians and an infectious diseases pharmacist), which was committed to implementing institutional measures to optimize the use of antimicrobials. In addition, there was an active and engaged Antimicrobial Subcommittee. This subcommittee, which remains in existence at the time of writing, consists of the infectious diseases team and a drug information pharmacist. It reports to the hospital’s Pharmacy and Therapeutics Committee, which in turn reports to the Medical Advisory Committee. Since 1993, the Antimicrobial Subcommittee had undertaken many antibiotic stewardship initiatives, including development of an antimicrobial handbook (updated annually), institutional antibiograms (also updated annually), provision of regular education about antimicrobials for pharmacists and medical residents, intermittent drug utilization audits, and development of policies for restricted antimicrobials, IV-to-oral step-down, and autosubstitution. In addition, the microbiology laboratory at this institution had adopted selective reporting of susceptibility results. In January 2007, the Infectious Diseases Society of Amer ica published guidelines for antimicrobial stewardship. On the basis of these guidelines, the SHSC Antimicrobial Subcommittee concluded that the 2 primary deficiencies in the hospital’s stewardship initiatives were the absence of prospective audit and feedback and the lack of a fully integrated database to enable impact assessment. It was recognized that implementing such services would not be feasible with the existing complement of pharmacists and physicians. As a result, the infectious diseases team submitted a business case for an antimicrobial stewardship program in autumn 2007, and the proposal was subsequently approved in concept. A formal antimicrobial stewardship team (AST) was formed in July 2009, with internal pharmacy support along with 2 years of physician funding through an award from the Ministry of Health and Long-Term Care Academic Health Sciences Centre Innovation Fund.