More research is needed into informing and optimizing antibiotic stewardship programs in hospitals, said the Society for Healthcare Epidemiology of America (SHEA).
These important research priorities include developing evidence to support best practices in a variety of settings, assessing optimal approaches to stewardship, developing outcome metrics to measure efforts, and approach study design with appropriate analytic methods, reported Andrew Morris, MD, of Sinai Health System-University Health Network Antimicrobial Stewardship Program in Toronto, and colleagues.
In other words, research into antibiotic stewardship needs to figure out what to do, how best to do it, how to measure what they are doing, and how to determine methods to improve stewardship practices, the authors wrote in , a journal of SHEA.
"Antibiotic stewardship is crucial to maintaining the effectiveness of life-saving treatments and preventing harm to patients and the wider community," said SHEA President Hilary Babcock, MD, in a statement. "We developed this research agenda to draw attention to serious gaps in our knowledge for future investigators and funders."
Morris further explained the gap in the U.S. government between public health research and clinical research where antibiotic stewardship often gets lost.
"The NIH funds science but won't fund stewardship because it is largely epidemiologically based and involves public health. The CDC funds public health, but it won't fund research that evaluates different interventions," he said.
The authors also discussed how these gaps in antibiotic stewardship research varied by healthcare settings, ranging from ambulatory care settings to emergency departments (EDs) to long-term care facilities. For ambulatory care, the authors emphasized the importance of appropriate prescribing for community-acquired infections, as well as meeting patient expectations for antibiotic prescribing and the role of public health campaigns to influence long-term antibiotic prescribing behaviors.
Issues in EDs involved examining the role of multi-disciplinary teams in antibiotic stewardship, as well as identifying appropriate staffing. The authors also posed the question: Would stewardship strategies that have been proven effective in primary care also be effective in the ED?
They noted that research into antibiotic stewardship in long-term care facilities is "limited," and has produced mixed results. The authors discussed the importance of collaboration between hospitals and post-acute care nursing facilities, and how best to improve communication about stewardship between prescribers and nurses.
Researchers also raised important patient-centric issues, such as when cultures from non-sterile sites are positive; how can clinicians distinguish between colonization and infection among patients with mental impairments; and who may not be able to report their symptoms.
From the healthcare facility to the practice of medicine itself, the authors said that additional clinical evidence is needed for optimal antibiotic use across a variety of infections, such as pneumonia.
They detailed the challenges of implementing antibiotic stewardship programs, starting with that concordance to guidelines to steer prescribing behavior is a flawed approach.
"National guidelines do not always prioritize treatment approaches, frequently exclude clinically relevant populations ([e.g.], immunocompromised patients, older adults, etc), and generally fail to address other aspects of infection management, such as the role of source control," the authors wrote.
They highlighted several diagnostic issues in pneumonia, mainly the need for more research in "imaging stewardship." The authors cited "ambiguities with the transcribing of imaging findings and atypical symptoms at presentation" that may lead clinicians to prescribing unnecessary antibiotics. They also noted the role of nasopharyngeal and sputum specimen testing and microbiological processing, as well as the role of biomarkers in diagnosis of upper respiratory tract infections.
"For most infections, we don't know the optimal drug, dose, or treatment duration. For many, we don't even know if they require antibiotic treatment," Morris said.
Disclosures
Morris and co-authors disclosed no relevant relationships with industry.
Primary Source
Infection Control & Hospital Epidemiology
Morris AM, et al "Research needs in antibiotic stewardship" Infect Control Hosp Epidemiology 2019; DOI: 10.1017/ice.2019.276.