diabetic foot infection , and intra-abdominal infections
• Use diagnostic stewardship to drive practice change in antibiotic prescribing
• Establish the role and optimal duration of antibiotic prophylaxis in a variety of settings , including in immunocompromised patients
Regarding implementation , Morris , et al . ( 2019 ) suggest that clinicians :
• Study various strategies to establish comparative effectiveness , feasibility , and costs
• Identify the most effective computerized decision support for AS interventions
• Incorporate social , organizational , emotional , and cultural drivers into the design of AS interventions
• Identify strategies for promoting dissemination of evidence-based stewardship in primary care , urgent care , and emergency departments
• Identify elements of sustainable AS
• Develop models for effective AS in varied ( non-acute care ) settings
• Identify key components of effective AS programs utilizing remote AS expertise and training of non-infectious diseases trained healthcare personnel
• Design cutting-edge implementation studies to scale up proven interventions
• Evaluate optimal staffing for AS
“ In an effort to combat antibiotic resistance , the federal government , as well as hospitals and health systems , are mandating antibiotic stewardship programs . However , we don ’ t know the optimal staffing for these programs or how they should function ,” Morris said . The paper notes that nurses have mostly been absent from antibiotic stewardship , and it calls for research to determine how best to engage bedside nurses in stewardship activities .
Courtenay , et al . ( 2020 ) addresses this deficit in a recent commentary , noting that the rapid emergence and dissemination of SARS-CoV-2 / COVID-19 has highlighted multiple areas in which competencies in antimicrobial stewardship ( AMS ), specifically by nurses , can support response efforts .
As the researchers observe , “ There have been calls for nurses to be recognized as legitimate contributors to AMS team efforts . Unfortunately , nurses ’ roles in these efforts have received minimal mention in international and national policies . It is reported that nurses ’ knowledge of antibiotics is poor , and that AMS taught in nurse undergraduate programs is disparate or lacking . To address this gap , AMS consensus-based international competency statements have been developed , focused on six domains ( infection prevention and control , antimicrobials and antimicrobial resistance , the diagnosis of infection and use of antibiotics , antimicrobial prescribing practice , person-centered care , interprofessional collaborative practice ), which are ( seen as ) priorities / minimum requirements for nurses .”
Courtenay , et al . ( 2020 ) continue , “ Nurses are often the first healthcare workers to come into contact with patients infected by SARS-CoV-2 , and thus need to be familiar with the signs and symptoms of the disease in order to ensure prompt implementation of additional precautions to stop transmission . Differentiating between viral and bacterial pneumonia can be challenging and thus awareness of how these symptoms differ is crucial . This awareness is central to reducing unnecessary prescriptions of not just antibiotics , as COVID-19 is caused by a virus , but other anti-infective drugs associated with AMS such as antifungal and antiviral medications . AMS requires nurses to be able to distinguish between symptoms and ask questions about the use of antibiotics , should symptoms be more consistent with a viral infection , or when microbiology results do not indicate a bacterial cause . Such actions will help to ensure that antimicrobial resistance is not an unintended consequence of COVID-19 .”
The researchers emphasize that AMS should be maintained during the COVID-19 pandemic , acknowledging that competing interests may have caused traditional AMS teams to “ fall apart ” during the public health crisis “ through repurposing of staff and the impact on microbiology services of supporting the COVID-19 workload ” as well as through “ reconfiguration of healthcare services , redeployment of healthcare workers into areas where they may have less expertise , and employment of retired practitioners who have less experience of antibiotic stewardship . This reshaping of interprofessional relations , with the addition of different professionals , with various professional backgrounds and experiences , potentially dilutes existing team cohesions , and could affect discussions and decisions about antimicrobial prescribing .”
The researchers encourage healthcare institutions to help empower nurses by applying AMS competencies to help nurses enact their AMS role , which in turn would enable sustainability of AMS activities during challenging times . They advise , “ Building competence to practice collaboratively enables nurses to be active participants in AMS policy decisions , and involves nurses taking advantage of opportunities to discuss antimicrobial treatment decisions and management plans with their colleagues , patients , and care-givers … COVID-19 has focused attention on nurse leaders ’ power and potential to promote AMS . A key AMS strategy in the current pandemic is to promote the message that antibiotics should not be prescribed for viral infections , and that these medicines must only be prescribed for those for whom serious bacterial ( primary or secondary ) infection is suspected . By involving nurses in AMS leadership positions , role modelling the importance of AMS behaviors , and advocating for , and supporting nurses in enacting their AMS role , a strong signal will be sent out to nurses about the importance of responsible antimicrobial management .”
While further research and investment in antibiotic stewardship is critical to improving and optimizing strategies , this research falls in the gaps between public health and clinical research , Morris says . “ Because antibiotic stewardship represents the interface of public health , epidemiological research , and clinical research , clear federal funding pathways need to be created . The National Institute of Health funds science but won ’ t fund stewardship because it is largely epidemiologically based and involves public health . The Centers for Disease Control and Prevention funds public health , but it won ’ t fund research that evaluates different interventions ,” Morris adds .
Morris acknowledges the numerous barriers to evidence-informed guidance .
“ The barriers are many , including the massive work required for evidence-based data synthesis , the need to look at treatment with an antimicrobial stewardship lens , and the multiple interest groups and stakeholders without a clear national strategy or framework for moving forward ,” he says . “ Since this [ whitepaper , Research Needs in Antibiotic Stewardship ] was written , it appears that IDSA is trying to fill in some of those gaps . Additionally , there are local resistance issues which add to the complexity of