Antibiotic
therapy must be
optimised when
possible not
only to benefit
our patient
preventing side
effects and risk
of new resistant
infections, but
also to decrease
overall resistance
patients. 27 C-reactive protein also plays a role in
AS. A recent trial in septic patients in ICU found
that C-reactive protein was as useful as PCT in
reducing antibiotic use, without apparent harm. 28
Biomarkers are a useful tool to guide
antibiotic disruption in sepsis, but cannot
substitute for the physician’s clinical expertise.
The levels of biomarkers must be carefully
interpreted according to the clinical condition
of the patient, but are an opportunity to improve
our care. PCT algorithms are incorporated into
many ASPs.
The impact of AS: expectations and concerns
The first actions designed to AS included three
goals as described Doron et al: to help physicians
to select the most appropriate antibiotic; to avoid
antibiotic overuse and abuse; and minimise the
progress of antimicrobial resistance. 29 Conscious
of the benefits of these three goals in the last 15
years, the ASPs are present in most of hospitals
and its presence has been promoted by
governments and Public Health organisations.
In this chapter we have summarised AS, who
does it, tools to do it and tools to do it with safety.
We need a culture change in antimicrobial
prescribing and we can assert that we are in this
process, despite barriers and the lack of evidence
supporting the efficacy of ASPs in resistance
development. Until recently, most studies were
observational and evidence was limited. Actually
some studies provide new attempts to support
ASPs in terms of resistance. Molina et al
conducted a quasi-experimental
multifaceted educational intervention focused
on ASPs in a tertiary-care hospital. They found a
sustained reduction in antimicrobial consumption
and a decreasing tendency on candidaemia,
multidrug-resistant bacteraemia and mortality
after the intervention. 30 Probably, more time is
needed to see the effect of these initiatives and
we will have to wait to observe its effect in
a global perspective.
The major concern with ASPs is the
phenomenon of ‘squeezing the balloon’:
diminishing the use of one type of antimicrobial
could result in an increasing utilisation of another,
with its associated resistance. An example is the
use of quinolones to treat Pseudomonas aeruginosa
infections that could result in carbapenem
resistance. 31 The use of guidelines and closed
surveillance provided by ASPs can allay this fear.
Conclusions
As clinicians, when we treat septic patients,
a broad-spectrum antimicrobial must be chosen
within the first hour to reduce the risk of
morbidity and mortality. But it is also necessary
to think beyond this. Antibiotic therapy must be
optimised when possible not only to benefit our
patient preventing side effects and risk of new
resistant infections, but also to decrease overall
resistance. This is the key to protecting patients
against potential multidrug-resistant infections.
Currently AS programmes are the best tool to use
in the hospital setting. Leadership, team work,
AS strategies, guidelines to control duration of
antibiotics and de-escalation, PCT-based algorithms
and new diagnostic stewardship approaches will
help to improve patient safety and decrease
antimicrobial resistance.
23
HHE 2018 | hospitalhealthcare.com
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