Surveillance alone plays a key role in curbing the overuse of antimicrobials: The major role of antibiotic stewardship

Abstract

Multidrug-resistant organisms are a growing problem in every facet of medicine globally. With the need to address this ever-increasing threat comes a need for new drugs and new interventions. Infections caused by multidrug-resistant organisms have resulted in high mortality and morbidity all over the world. This is because there are few, if any, pharmaceutical and antimicrobial options to treat them. The pipeline is running dry, and a ‘nil-antibiotic’ era is approaching. It’s a scary thought – no effective antimicrobial agent available anywhere in the world. We need to conserve what we have, and the answer lies in antimicrobial stewardship. If put into practice, this will assist in curbing the problem of multidrug-resistant organisms. The fight against these pathogens and the struggle to conserve antimicrobials have many facets, but surveillance remains the key. Antimicrobial stewardship is a team approach and involves many aspects of healthcare, working towards a common goal. A recent study in the trauma intensive care unit (ICU) at Inkosi Albert Luthuli Central Hospital in Durban, South Africa, highlights the key role that surveillance alone plays in curbing overuse of antimicrobials and reducing multidrug resistance. [1] Surveillance was key to establishing the flora typical of the unit and to choosing empiric therapy, with the help of an antibiogram based on the findings of the surveillance. Patients admitted to the unit were started on empiric therapy when they presented with sepsis. In more than 90% of cases, empiric therapy proved appropriate. Importantly, there was no need to use initial ultrabroad-spectrum therapy regimens in the form of a carbapenem, a glycopeptide and an antifungal. Most ICUs around the world employ a de-escalation strategy whereby ultrabroad-spectrum therapy is used and then tailored down or de-escalated once microbiological cultures become available. The Durban study highlights the fact that surveillance and knowledge of local flora plus antimicrobial susceptibility patterns make it possible to use more tailored, narrow-spectrum antimicrobials. Because there is no overuse of broad-spectrum antimicrobials, the emergence of multidrug-resistant pathogens is curbed. Antimicrobial stewardship is a key component of the multifaceted approach to preventing antimicrobial resistance. Good antimicrobial stewardship involves selecting an appropriate drug and optimising its dose and duration to cure an infection, while minimising toxicity and the conditions that might select for resistant bacterial strains. With such an active surveillance programme and empiric antimicrobial policy, blanket cover is rarely indicated. The empiric choice of antimicrobials should cover the most likely pathogens, endemic to the specific location. It is important to note that this does not refer to all pathogens, and prescriptions cannot be based on uncommon organisms unless the situation dictates the need. There are many challenges to successful stewardship, but its aims are education, prevention of antimicrobial overuse, and minimising