Antibiotic Strategy and Stewardship

  • Sarah M. KolnikEmail author
  • Heather L. Evans


Antibiotic stewardship is the optimization of antibiotic regimens to ensure the best treatment selection for individual patients with minimization of side effects and cost while attempting to limit the development of resistance (MacDougall and Polk, Clin Microbiol Rev 18(4):638–656, 2005; Luyt et al., 1–12, 2014). Comprehensive antibiotic management strategies may use a variety of methods to limit antibiotic use in volume, duration, and spectrum. These strategies should also include multidisciplinary efforts to monitor compliance with clinical practice guidelines, policies, and protocols. Formulary restriction, antibiotic cycling, selective reporting of culture susceptibilities, and decision support tools to aid in drug selection are among the means by which antimicrobial use can be directed. Equally important in the critical care setting is the prevention and treatment of nosocomial infections common to critically ill patients.


Antibiotic stewardship Nosocomial infections Infection prevention 


  1. 1.
    MacDougall C, Polk RE. Antimicrobial stewardship programs in health care systems. Clin Microbiol Rev. 2005;18(4):638–56.CrossRefGoogle Scholar
  2. 2.
    Luyt C-E, Chot NB, Trouillet J-L, Chastre J. Antibiotic stewardship in the intensive care unit. Critical Care. 2014;18(5):2014:480.Google Scholar
  3. 3.
    Antimicrobial resistance: global report on surveillance. World Health Organization Publication; 2014. p. 1–256.Google Scholar
  4. 4.
    CDC AZ. US Department of Health and Human Services. Antibiotic resistance threats in the United States, 2013. Atlanta: CDC (2013).Google Scholar
  5. 5.
    Davey P, Brown E, Charani E, Fenelon L, Gould IM, Holmes A, et al. Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database Syst Rev. 2013;(4):CD003543. Chichester: John Wiley & Sons, Ltd.Google Scholar
  6. 6.
    Malani AN, Richards PG, Kapila S, Otto MH, Czerwinski J, Singal B. Clinical and economic outcomes from a community hospital’s antimicrobial stewardship program. Am J Infect Control. 2013;41(2):145–8.CrossRefGoogle Scholar
  7. 7.
    Carling P, Fung T, Killion A, Terrin N, Barza M. Favorable impact of a multidisciplinary antibiotic management program conducted during 7 years. Infect Control Hosp Epidemiol. 2003;24(9):699–706.CrossRefGoogle Scholar
  8. 8.
    Larson EL, Quiros D, Giblin T, Lin S. Relationship of antimicrobial control policies and hospital and infection control characteristics to antimicrobial resistance rates. Am J Crit Care. 2007;16(2):110–20.PubMedPubMedCentralGoogle Scholar
  9. 9.
    Young EJ, Sewell CM, Koza MA. Antibiotic resistance patterns during aminoglycoside restriction. Am J Med Sci. 1985;290:223–7.CrossRefGoogle Scholar
  10. 10.
    White AC, Atmar RL, Wilson J, Cate TR, Stager CE, Greenberg SB. Effects of requiring prior authorization for selected antimicrobials: expenditures, susceptibilities, and clinical outcomes. Clin Infect Dis. 1997;25(2):230–9.CrossRefGoogle Scholar
  11. 11.
    Aubert G, Carricajo A, Vautrin AC, Guyomarc’h S, Fonsale N, Page D, et al. Impact of restricting fluoroquinolone prescription on bacterial resistance in an intensive care unit. J Hosp Infect. 2005;59(2):83–9.CrossRefGoogle Scholar
  12. 12.
    May AK, Melton SM, McGwin G, Cross JM, Moser SA. Reduction of vancomycin-resistant enterococcal infections by limitation of broad-spectrum cephalosporin use in a trauma and burn intensive care unit. Shock. 2000;14:259–64.CrossRefGoogle Scholar
  13. 13.
    Burke JP. Antibiotic resistance – squeezing the balloon? JAMA. 1998;280(14):1270–1.CrossRefGoogle Scholar
  14. 14.
    Allegranzi B, Luzzati R, Luzzani A, Girardini F, Antozzi L, Raiteri R, et al. Impact of antibiotic changes in empirical therapy on antimicrobial resistance in intensive care unit-acquired infections. J Hosp Infect. 2002;52(2):136–40.CrossRefGoogle Scholar
  15. 15.
    Zillich AJ, Sutherland JM, Wilson SJ, Diekema DJ, Ernst EJ, Vaughn TE, et al. Antimicrobial use control measures to prevent and control antimicrobial resistance in US Hospitals. Infect Control Hosp Epidemiol. 2006;27(10):1088–95.CrossRefGoogle Scholar
  16. 16.
    Gerding DN, Larson TA, Hughes RA, Weiler M, Shanholtzer C, Peterson LR. Aminoglycoside resistance and aminoglycoside usage: ten years of experience in one hospital. Antimicrob Agents Chemother. 1991;35(7):1284–90.CrossRefGoogle Scholar
  17. 17.
    Kollef MH, Vlasnik J, Sharpless L, Pasque C, Murphy D, Fraser V. Scheduled change of antibiotic classes: a strategy to decrease the incidence of ventilator-associated pneumonia. Am J Respir Crit Care Med. 1997;156:1040–8.CrossRefGoogle Scholar
  18. 18.
    Gruson D, Hilbert G, Vargas F, Valentino R, Bebear C, Allery A, et al. Rotation and restricted use of antibiotics in a medical intensive care unit. Impact on the incidence of ventilator-associated pneumonia caused by antibiotic-resistant gram-negative bacteria. Am J Respir Crit Care Med. 2000;162(3 Pt 1):837–43.CrossRefGoogle Scholar
  19. 19.
    Bergstrom CT, Lo M, Lipsitch M. Ecological theory suggests that antimicrobial cycling will not reduce antimicrobial resistance in hospitals. Proc Natl Acad Sci U S A. 2004;101:13285–90.CrossRefGoogle Scholar
  20. 20.
    Raymond DP, Pelletier SJ, Crabtree TD, Gleason TG, Hamm LL, Pruett TL, et al. Impact of a rotating empiric antibiotic schedule on infectious mortality in an intensive care unit. Crit Care Med. 2001;29(6):1101–8.CrossRefGoogle Scholar
  21. 21.
    Hughes MG, Evans HL, Chong TW, Smith RL, Raymond DP, Pelletier SJ, et al. Effect of an intensive care unit rotating empiric antibiotic schedule on the development of hospital-acquired infections on the non–intensive care unit ward. Crit Care Med. 2004;32(1):53–60.CrossRefGoogle Scholar
  22. 22.
    Piper GM, Kaplan LJ. Antibiotic heterogeneity optimizes antimicrobial prescription and enables resistant pathogen control in the Intensive Care Unit. Surg Clin N Am. 2012;13(4):194–202.Google Scholar
  23. 23.
    Boyce JM, Pittet D. Guideline for Hand Hygiene in Health-Care Settings. Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HIPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Am J Infect Control. 2002;30:S1–46.CrossRefGoogle Scholar
  24. 24.
    Naikoba S, Hayward A. The effectiveness of interventions aimed at increasing handwashing in healthcare workers – a systematic review. J Hosp Infect. 2001;47(3):173–80.CrossRefGoogle Scholar
  25. 25.
    Girou E, Loyeau S, Legrand P, Oppein F, Brun-Buisson C. Efficacy of handrubbing with alcohol based solution versus standard handwashing with antiseptic soap: randomised clinical trial. BMJ. 2002;325(7360):362.CrossRefGoogle Scholar
  26. 26.
    Safdar N, Marx J, Meyer NA, Maki DG. Effectiveness of preemptive barrier precautions in controlling nosocomial colonization and infection by methicillin-resistant Staphylococcus aureus in a burn unit. Am J Infect Control. 2006;34(8):476–83.CrossRefGoogle Scholar
  27. 27.
    Mangini E, Segal Maurer S, Burns J, Avicolli A, Urban C, Mariano N, et al. Impact of contact and droplet precautions on the incidence of hospital‐acquired methicillin‐resistant staphylococcus aureus Infection. Infect Control Hosp Epidemiol. 2007;28(11):1261–6.CrossRefGoogle Scholar
  28. 28.
    Climo MW, Yokoe DS, Warren DK, Perl TM, Bolon M, Herwaldt LA, et al. Effect of daily chlorhexidine bathing on hospital-acquired infection. N Engl J Med. 2013;368(6):533–42.CrossRefGoogle Scholar
  29. 29.
    Noto MJ, Domenico HJ, Byrne DW, Talbot T, Rice TW, Bernard GR, et al. Chlorhexidine bathing and health care–associated infections. JAMA. 2015;313(4):369.CrossRefGoogle Scholar
  30. 30.
    Calfee DP, Salgado CD, Milstone AM, Harris AD, Kuhar DT, Moody J, et al. Strategies to prevent methicillin-resistant Staphylococcus aureus transmission and infection in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol. 2014: 35;S108–S132.Google Scholar
  31. 31.
    American Thoracic Society; Infectious Diseases Society of America. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med. 2005;171(4):388–416.CrossRefGoogle Scholar
  32. 32.
    Michelet P, Couret D, Brégeon F, Perrin G, D’Journo X-B, Pequignot V, et al. Early onset pneumonia in severe chest trauma: a risk factor analysis. J Trauma: Inj Infect Crit Care. 2010;68(2):395–400.CrossRefGoogle Scholar
  33. 33.
    DeRiso AJ, Ladowski JS, Dillon TA, Justice JW, Peterson AC. Chlorhexidine gluconate 0.12% oral rinse reduces the incidence of total nosocomial respiratory infection and nonprophylactic systemic antibiotic use in patients undergoing heart surgery. Chest. 1996;109(6):1556–61.CrossRefGoogle Scholar
  34. 34.
    Shi Z, Xie H, Wang P, Zhang Q, Wu Y, Chen E, Ng L, Worthington HV, Needleman I, Furness S. Oral hygiene care for critically ill patients to prevent ventilator-associated pneumonia. Cochrane Database Syst Rev. 2013 Jan 1;8.Google Scholar
  35. 35.
    O’Grady NP, Alexander M, Burns LA, Dellinger EP, Garland J, Heard SO, Lipsett PA, Masur H, Mermel LA, Pearson ML, Raad II. Guidelines for the prevention of intravascular catheter-related infections. Clinical infectious diseases. 2011;52(9):e162–93.CrossRefGoogle Scholar
  36. 36.
    Pronovost P, Needham D, Berenholtz S, Sinopoli D, Chu H, Cosgrove S, Sexton B, Hyzy R, Welsh R, Roth G, Bander J, Kepros J, Goeschel C. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med. 2006;355:2725–32.CrossRefGoogle Scholar
  37. 37.
    Horan TC, Andrus M, Dudeck MA. CDC/NHSN surveillance definition of health care-associated infection and criteria for specific types of infections in the acute care setting. Am J Infect Control. 2008;36:309–32.CrossRefGoogle Scholar
  38. 38.
    Chenoweth CE, Gould CV, Saint S. Diagnosis, management, and prevention of catheter-associated urinary tract infections. Infect Dis Clin North Am. 2014;28(1):105–19.CrossRefGoogle Scholar
  39. 39.
    Shuman EK, Chenoweth CE. Recognition and prevention of healthcare-associated urinary tract infections in the intensive care unit. Crit Care Med. 2010;38:S373–9.CrossRefGoogle Scholar
  40. 40.
    Nicolle LE. Urinary catheter-associated infections. Infectious disease clinics of North America. 2012;26(1):13–27.CrossRefGoogle Scholar
  41. 41.
    Ramanathan R, Duane TM. Urinary tract infections in surgical patients. Surg Clin North Am. 2014;94(6):1351–68.CrossRefGoogle Scholar
  42. 42.
    Luciano JA, Zuckerbraun BS. Clostridium difficile infection: prevention, treatment, and surgical management. Surgical Clinics of North America. 2014;94(6):1335–49.CrossRefGoogle Scholar
  43. 43.
    Lessa FC, Mu Y, Bamberg WM, Beldavs ZG, Dumyati GK, Dunn JR, et al. Burden of Clostridium difficile infection in the United States. N Engl J Med. 2015;372(9):825–34.CrossRefGoogle Scholar
  44. 44.
    Cohen SH M.D., Gerding DN M.D., Johnson S M.D., Kelly CP M.D., Loo VG M.D., McDonald LC M.D. Clinical Practice Guidelines for Clostridium difficile Infection in Adults: 2010 Update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA). Infect Control Hosp Epidemiol. 2010;31(5):431–55.CrossRefGoogle Scholar
  45. 45.
    Neal M, Alverdy JC, Hall DE, et al. Diverting loop ileostomy and colonic lavage: an alternative to total abdominal colectomy or the treatment of severe, complicated Clostridium difficile associated disease. Ann Surg. 2011;254(3):423–9.CrossRefGoogle Scholar
  46. 46.
    Garnacho-Montero J, Gutierrez-Pizarraya A, Escoresca-Ortega A, et al. De-escalation of empirical therapy is associated with lower mortality in patients with severe sepsis and septic-shock. Int Care Med. 2014;40:32–40.CrossRefGoogle Scholar
  47. 47.
    Jones M, Huttner B, Madaras-Kelly K, et al. Parenteral to oral conversion of fluoroquinolones: low-hanging fruit for antimicrobial stewardship programs? Infect Control Hosp Epidemiol. 2012;33(4):362–7.CrossRefGoogle Scholar

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Authors and Affiliations

  1. 1.General SurgeryUniversity of WashingtonSeattleUSA

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