Abstract
For decades, the performance of antimicrobial stewardship programs (ASPs) has been measured by incidence rates of hospital-onset Clostridioides difficile and other infections due to multidrug-resistant bacteria. However, these represent indirect and nonspecific ASP metrics. They are often confounded by factors beyond an ASP’s control, such as changes in diagnostic testing methods or algorithms and the potential of patient-to-patient transmission. Whereas these metrics remain useful for global assessment of healthcare systems, antimicrobial use represents a direct metric that separates the performance of an ASP from other safety and quality teams within an institution. The evolution of electronic medical records and healthcare informatics has made measurements of antimicrobial use a reality. The US Centers for Disease Control and Prevention’s initiative for reporting antimicrobial use and standardized antimicrobial administration ratio in hospitals is highly welcomed. Ultimately, ASPs should be evaluated based on what they do best and what they can control, that is, antimicrobial use within their own institution. This narrative review critically appraises existing stewardship metrics and advocates for adopting antimicrobial use as the primary performance measure. It proposes novel formulas to adjust antimicrobial use based on quality of care and microbiological burden at each institution to allow for meaningful inter-network and inter-facility comparisons.
Highlights
Importance of Antimicrobial Stewardship MetricsIt is imperative for the success of any antimicrobial stewardship program (ASP) to have objective measures for performance evaluation
Since the incidence of hospital-onset CDI (HO-CDI) and infections with MDR bacteria may be reduced by Infection Prevention and Control Program efforts, antimicrobial use remains the only metric which differentiates the performance of ASPs from other patient safety and quality teams
Most ASPs would not be bothered if the decline in antimicrobial use of broad-spectrum agents was accompanied by an increase in antimicrobial use of narrower-spectrum agents
Summary
It is imperative for the success of any antimicrobial stewardship program (ASP) to have objective measures for performance evaluation. Direct measurement of ASP performance via process measures (e.g., antimicrobial use) and/or outcome measures (e.g., Clostridioides difficile infection [CDI]) is currently recommended by clinical guidelines to improve quality care and prevent antimicrobial resistance [1]. This process ensures that both hospital administration and ASP team members have consistent goals and expectations. It was convenient to use the incidence rate of HO-CDI as a metric for both Infection Prevention and Control Programs and ASPs. The requirement for hospitals within the United States to publicly report the incidence rate of HO-CDI through National Healthcare Safety Network (NHSN) and paucity of other measures of ASP performance only emphasized this existing concept.
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