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REVIEW ARTICLE
Antibiotic Stewardship
Using Clinical Guidelines to Control Antibiotic Overuse and
Deter Microbial Adaptation
Clifford G. Wlodaver, MD*Þ and Christopher May, PharmDþ
Abstract: The multidrug-resistant organism and Clostridium difficile
epidemics, which are adverse consequences of antibiotic use, continue
to grow. Antibiotic stewardshipVa program aimed at the judicious use
of antibioticsVis a deterrent. Yet, its implementation, whether through
prospective audit with intervention and feedback or by formulary restriction and preauthorization, experiences the underuse of clinical guidelines
for when antibiotics should be withheld and withdrawn. This article is
the first to catalog and summarize the guidelines for controlling antibiotic
overuse to facilitate their implementation. Conditions for which antibiotics
are not justified include nonbacterial respiratory syndromes, asymptomatic bacteriuria, colonization and culture contamination, selected cases of
acute otitis media and skin and soft tissue infections, and ‘‘low-grade’’
fever. Traditionally accepted durations should be shortened for acute
exacerbations of chronic bronchitis, pneumonias, urinary tract infections,
intra-abdominal infections, Staphylococcus aureus bacteremia, and surgical prophylaxis. Studies demonstrate that guideline implementation
through antibiotic stewardship can enhance outcomes and decrease resistance. Unfamiliarity with the guidelines should be addressed by their more
widespread dissemination. Their imperfections should be addressed by
more placebo-controlled trials. Concerns of undertreatment need to be
counterbalanced by the adverse consequences of overtreatment. We believe
that regulatory agencies should consider promoting antibiotic stewardship.
Key Words: antibiotic stewardship, antibiotic overuse,
multidrug-resistant organisms, Clostridium difficile
(Infect Dis Clin Pract 2012;20: 12Y17)
T
hat antibiotics perform countless benefits is uncontroversial.
Yet, their use and misuse are the root cause for microbial
adaptation resulting in the multidrug-resistant organism (MDRO)
and Clostridium difficile (CDI) epidemics.1,2 This natural selection was predicted by Fleming3 in his Nobel Prize lecture on
discovering penicillin. Because antibiotics are relatively so effective, safe, and inexpensive, these are used liberally and are
prone to overuse. Too little attention has been paid to when not to
use antibiotics. Prescribing these is often more comfortable than
practicing the necessary restraint. Antibiotic stewardship (ABS)V
a program aimed at the judicious use of antibioticsVhas evolved
to address this problem.4 The process involves reviewing patients
who are receiving antibiotics and then making recommendations for change, when indicated, using guidelines to adjust the
delicate balance between use and misuse. Whether ABS takes the
strategy of ‘‘prospective audit with intervention and feedback’’ or
‘‘formulary restriction and preauthorization’’4 and whether it uses
clinical pathways, educational programs, and/or computerized
systems, the clinical challenge is in distinguishing when a patient
in fact has a bacterial infection meriting antibiotics and, if so,
when these can be safely discontinued. The current trend is to give
antibiotics freely, sometimes injudiciously, out of concern for
mistakenly omitting treatment, that is, the ‘‘just-in-case’’ approach. Concerns about relapse often result in unnecessary prolongation. Antibiotic duration is in fact based more on tradition
than on scientific evidence.5 Although the concept of ABS is
not new, its literature has been relatively vague on translating the
guidelines into specific interventions, and these are used irregularly. To facilitate their implementation, we have collected and
summarized the guidelines. Their implementation should reduce
the incidence of MDRO and CDI.6Y9 We need a paradigm shift.
WHEN TO WITHHOLD AND WHEN TO
WITHDRAW ANTIBIOTICS
Respiratory Tract Syndromes
Acute Pharyngitis
Most cases of acute pharyngitis are viral and should not be
treated with antibiotics.10 The Centers for Disease Control promote antibiotic restraint through their ‘‘Get Smart’’ campaign.11
However, 15% to 30% of pediatric cases and 5% to 10% of
adult cases are caused by group A streptococcus. This is the only
common bacterial cause of pharyngitis meriting antibiotics, the
other bacteria being very rare. Yet, Linder and Stafford12 reported that three fourths of adults who consulted their physician
for a sore throat received antibiotics. It is therefore important
to exclude streptococcal pharyngitis to avoid unnecessary antibiotics. Because distinguishing it from a respiratory virus is
difficult on clinical grounds alone, the use of rapid antigen detection testing reflexed to culture is recommended before starting
antibiotics.13
Acute Rhinosinusitis
Most cases of acute rhinosinusitis are also viral.10 To decrease the use of unnecessary antibiotics, waiting 10 days is
recommended if the clinical severity is mild and is stable or
improving.14 This is because most viruses and even some bacterial infections resolve spontaneously within this period.
Acute Bronchitis
From the *Midwest Regional Medical Center, Midwest City; †College of
Medicine, The University of Oklahoma Health Sciences Center, Oklahoma
City; and ‡Department of Pharmacy, Midwest Regional Medical Center,
Midwest City, OK.
Correspondence to: Clifford G. Wlodaver, MD, 8121 National Ave,
Suite 310, Midwest City, OK 73110. E-mail: [email protected].
The authors have no funding or conflicts of interest to disclose.
Copyright * 2012 by Lippincott Williams & Wilkins
ISSN: 1056-9103
12
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Although most cases of acute bronchitis are viral in origin,10
acute exacerbations of chronic bronchitis may have a bacterial
component.15 Criteria for when to use antibiotics are proposed
in the Global Initiative for Chronic Obstructive Lung Disease
(GOLD) report, namely, dyspnea, increased sputum volume
and purulence, and systemic symptoms and signs of infection.16 If
antibiotics are decided upon, an abbreviated course may suffice.
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Volume 20, Number 1, January 2012
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Infectious Diseases in Clinical Practice
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Volume 20, Number 1, January 2012
For example, a 3-day course of amoxicillin-clavulanate was as
effective as a 10-day course in microbiological success, symptom
recovery, use of corticosteroids, duration of oxygen therapy, and
length of hospital stay.17
Community-Acquired Pneumonia
Community-acquired pneumonia (CAP) merits antibiotics,
and the time to first antibiotic dose has become a core measure
of a hospital’s quality of care by the Centers for Medicare and
Medicaid Services (CMS) Hospital Quality Alliance and Joint
Commission. The present cutoff is 6 hours.18 Feeling the pressure of time constraints, especially in emergency departments,
and confronted with diagnostic uncertainty, physicians often
prescribe antibiotics prematurely. Congestive heart failure and
other cardiopulmonary disorders may be mistakenly diagnosed
as CAP. When the time to first antibiotic dose was shorter
(G4 hours) compared with longer (98 hours), Welker et al19
found that the final diagnosis at dischargeVCAP versus other
cardiopulmonary disordersVdid not meet predefined criteria for
CAP 39% of the time. Chest x-ray reports that read ‘‘probable
vascular congestion, cannot rule out pneumonia,’’ appear frequently and invite prescriptions for antibiotics. Careful review of
the patient’s history and physical examination along with the
white blood cell count, sputum examination, urine antigen tests,
and B-type natriuretic peptide can help to distinguish between
congestive heart failure and CAP. Ultimately, when pneumonia
seems unlikely, antibiotics should be discontinued.
Recent studies suggest that a shorter (5 days) rather than
longer course of antibiotics is sufficient for CAP, and this has
received recognition from the Infectious Diseases Society of
America (IDSA) and American Thoracic Society (ATS).20 These
societies also remind us not to base duration on chest radiograph
normalization because infiltrate resolution may lag clinical
recovery.
Health CareYAssociated Pneumonia
Similar to CAP, health careYassociated pneumonia requires
a shorter duration of antibiotics than previously believed. Eight
days of therapy is adequate for patients who are not infected with
nonfermenting gram-negative bacilli.21
Acute Otitis Media in Children
According to the American Academy of Pediatrics and
American Academy of Family Physicians Clinical Practice
Guideline, ‘‘Observation without use of antibacterial agents in a
child with uncomplicated AOM is an option for selected children
based on diagnostic certainty, age, illness severity, and assurance
of follow-up. (This option is based on randomized, controlled
trials with limitations and a relative balance of benefit and
risk.)’’22 Although concerns that antibiotic restraint may result in
an increased incidence of mastoiditis have been raised, this has
not been the case. ‘‘Placebo-controlled trials of AOM over the
past 30 years have shown consistently that most children do well,
without adverse sequelae, even without antibiotic therapy.’’22
Since these guidelines were written, 2 placebo-controlled
trials that support early antibiotic treatment of acute otitis media
(AOM) have been published. Tähtinen et al23 showed a 62%
reduction in treatment failure and an 81% reduction for rescue
therapy, and Hoberman et al24 showed earlier and more sustained
resolution of symptoms with therapy. As pointed out in an accompanying editorial, diagnostic accuracy is the key to management.25 If the child in fact has a bacterial infection, early
initiation of antibiotics is beneficial.
* 2012 Lippincott Williams & Wilkins
Antibiotic Stewardship
Skin and Soft Tissue Infections
Cutaneous Abscesses
Cutaneous abscesses respond to incision and drainage alone
and do not require antibiotics, with the following exceptions:
‘‘severe or extensive disease (eg, involving multiple sites of infection) or rapid progression in presence of associated cellulitis,
signs and symptoms of systemic illness, associated comorbidities
or immunosuppression, extremes of age, abscess in area difficult
to drain (eg, face, hand, and genitalia), associated septic phlebitis,
and lack of response to I & D alone.’’26
Cellulitis
For cellulitis, it is important to distinguish whether it
is purulent or not. Purulence is more often associated with
methicillin-resistant Staphylococcus aureaus, whereas the absence
of purulence suggests A-hemolytic streptococcus. Empirical antibiotics need to be selected accordingly.26 When antibiotics are
used for skin and soft tissue infections (SSTIs), Jenkins et al27
noted their inappropriately long duration. They found that the
median duration was nearly 13 days and cited evidence that 5 days
should suffice.28
Lower Extremity Venous InsufficiencyYAssociated
Stasis Dermatitis
Lower extremity venous insufficiencyYassociated stasis dermatitis, a locus minoris resistancia, may become acutely infected,
thus meriting antibiotics. However, the stable, chronic bilateral
inflammation that typifies stasis dermatitis should not be treated
with antibiotics.29
Urinary Tract Infections
Asymptomatic Bacteriuria and Pyuria in Adults
Asymptomatic bacteriuria and pyuria in adults do not merit
treatment (except in pregnancy and when associated with a
urologic procedure). Abundant literature indicates the absence
of any treatment benefit.30 It does not lead to hypertension,
chronic kidney disease, genitourinary cancer, or decreased survival. Antibiotics do not decrease the incidence of symptomatic infection. The IDSA Guidelines conclude that ‘‘Itreatment
of asymptomatic bacteriuria does not decrease the frequency
of symptomatic infection or improve other outcomes. Thus, in
populations other than those for whom treatment has been documented to be beneficial [pregnancy and urologic procedures],
screening for or treatment of asymptomatic bacteriuria is not
appropriate and should be discouraged.’’30 A urine culture should
not be done unless a patient has a syndrome compatible with a
urinary tract infection (UTI). However, recent movements to report hospital-acquired infections and the CMS’ new regulations
that deny reimbursement for hospital-acquired UTIs have led
some hospitals to routinely culture urine upon admission and to
document bacteriuria (if present), to avoid subsequent accusations of hospital-acquired infections and reimbursement-denial
issues, respectively.31 Furthermore, intuition argues to treat, and
practitioners often do not feel comfortable disregarding bacteriuria and pyuria once they learn of its presence. Not only does
screening not improve outcomes, but it may also lead to the unnecessary use of antibiotics and their unintended consequences,
as reaffirmed by the US Preventive Services Task Force.32 To
deal with the dilemma, there is a burgeoning movement to increase adherence to nontreatment guidelines. Gross and Patel33
have proposed a national performance measure for not treating
asymptomatic bacteriuria. For patients with indwelling urinary
catheters, it is likewise important to distinguish asymptomatic from
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Wlodaver and May
Infectious Diseases in Clinical Practice
symptomatic bacteriuria. Similar to asymptomatic bacteriuria in
noncatheterized patients, evidence-based guidelines proscribe culturing for and treating asymptomatic bacteriuria (except in pregnancy and when associated with a urologic procedure).34
The IDSA Guidelines for treating symptomatic UTIs are
type (cystitis or pyelonephritis), pathogen, and drug specific.35 In essence, they recommend nitrofurantoin monohydrate/
macrocrystals for 5 days or trimethoprim-sulfamethoxazole for
3 days (if local resistance G20%) for acute cystitis. In some
instances, trimethoprim alone is used. The guidelines also discuss other choices based on availability outside North America.
Although efficacious, the fluoroquinolones should be reserved
for resistant organisms because of their potential for ‘‘collateral
damage.’’ Because of inferior efficacy and more adverse effects,
A-lactam agents, in general, ‘‘should be used with caution,’’ and
ampicillin and amoxicillin should not be used for empirical
treatment because of the high prevalence of resistance. For
acute pyelonephritis, the guidelines recommend ciprofloxacin
when the community prevalence of resistance is less than 10%,
considering the initial dose given intravenously (IV), or using an
initial IV dose of ceftriaxone or an aminoglycoside if the community resistance to quinolones is more than 10%. In patients
not requiring hospitalization, provided that the pathogen is susceptible, oral levofloxacin for 5 days, ciprofloxacin for 7 days, or
trimethoprim-sulfamethoxazole for 14 days is an appropriate
choice. A-lactams are relatively less effective than other agents. If
used, the recommended duration is 10 to 14 days. For catheterassociated UTIs, 7 days is recommended, prolonged to 10 to
14 days for a delayed response.35 The antibiotic regimen should
always be tailored to the susceptibility results.
Bacteremia
Cultures of blood that grow coagulase-negative staphylococci and other normal skin flora often represent contamination
and do not merit antibiotics, although these need to be considered carefully when associated with intravascular catheters and
bioprostheses. Multiple samples and quantitative cultures help
distinguish contamination from true infection.36
The duration of antibiotics for Staphylococcus aureus bacteremia has been addressed by Fowler et al,37 with a risk score for
estimating the likelihood of developing complications. Four factors were noted to be related to the development of complications:
community-acquired skin findings suggestive of acute systemic
infection, fever for more than 3 days, and positive follow-up blood
cultures at 48 to 96 hours. One point is given to each of the first
3 factors, and 2 points are given to the last. The risk of developing complications was 16% for no factors and rose steadily to 90%
for all factors. Accordingly, a shorter course (eg, 2 weeks) of
antibiotics may suffice in the absence of risk factors, whereas 4
to 6 weeks is indicated when there are more risk factors.
Intra-Abdominal Infections
Guidelines for the duration of antibiotics for complicated
intra-abdominal infections by the Surgical Infection Society and
IDSA state that it should be limited to 4 to 7 days, as long as
there is adequate source control.38 A longer duration has not
been shown to improve outcomes.
Surgical Prophylaxis
Antibiotics for surgical prophylaxis decrease the risk of
surgical site infection.39,40 Although these are traditionally
prolonged in the perioperative period, evidence shows no benefit
beyond the immediate preoperative dose. The first dose should
be given within 60 minutes of the surgical incision (120 minutes
for vancomycin or fluoroquinolones). For prolonged procedures
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or when there has been a significant delay in starting the operation, a second dose at 1 to 2 half-lives is recommended. Prophylactic antibiotics should not be continued beyond 24 hours after
the end of surgery, without exception.40 Continuing them until
the surgical drains are removed is of unproven benefit. For dirty/
contaminated surgery, antibiotics should be continued beyond
24 hours.
‘‘Low-Grade’’ Fever
Elevated temperature is the hallmark of infection and drives
consideration for antibiotic use. A temperature of 98.6-F
(37.0-C) has been the time-honored maximum normal body
temperature. However, Mackowiak et al41 demonstrated that
99.9-F (37.7-C) is the true normal maximum temperature by
measuring the temperatures of 148 healthy men and women aged
18 to 40 years using an oral electronic digital thermometer. Lowgrade fever, that is, with a temperature less than 99.9-F, should
not be treated with antibiotics or used as a reason to continue
these unless there are other signs or symptoms of infection.
OUTCOMES
Several studies have demonstrated that ABS can increase
the appropriateness of antibiotics. This translates into decreased
use, decreased resistance, and decreased CDI. Gross et al6 compared usual practice to a university hospital program and noted a
statistically significant increase in appropriate antibiotic use from
32% to 90% and in cure from 55% to 91% and a decrease in
resistance from 9% to 1%. Methicillin-resistant S. aureus and
C. difficile rates decreased significantly after implementation of
a stewardship program reported by Fowler et al,8 and the rate of
resistant Enterobacter decreased significantly on a stewardship
program reported by Carling et al.7 A nationwide campaign in
France to reduce antibiotic use entitled ‘‘Antibiotics Are Not
Automatic’’ decreased the mean number of prescriptions from
72.4 to 56.6 per 100 people from 2000Y2001 to 2006Y2007.9
DISCUSSION
The MDRO and CDI epidemics are progressing rapidly.
Their significance, association with antibiotic use, and the limitations these place on antibiotic therapy are discussed in detail
elsewhere.1,2 Antibiotic stewardship offers a deterrent.6Y9 However, translating its concepts into practice is inconsistent (whether
ABS takes the strategy of ‘‘prospective audit with intervention
and feedback’’ or ‘‘formulary restriction and preauthorization’’4)
as evidenced by these uncontrolled epidemics and is the focus of
this article. We decided to divide our perspectives into 2 broad
categories: when not to use antibiotics in the first place (Table 1)
and when to discontinue these once in use (Table 2). For support,
we decided to focus on published clinical guideline recommendations, when available, rather than citing the primary studies
upon which these are based. Limiting antibiotic exposure is applicable in academic and nonacademic situations to both adult
and pediatric infections and in inpatient and outpatient settings,
as noted in the broad scope of the recommendations that we have
listed. Guidelines also exist for ABS in febrile neutropenic patients,42 and the concepts apply to intensive care unit patients as
well.43 Although the intent of our article is to catalog when to
judiciously withhold and withdraw antibiotics, in these complex
and critically ill patients, multiple antibiotics for prolonged duration may be required. These patients may be more appropriately
addressed by a face-to-face infectious diseases consultation.
The decision whether to use antibiotics is based on clinical
judgment. For a septic patient, timely, appropriate empirical
treatment can be lifesaving. Then, once a pathogen has been
* 2012 Lippincott Williams & Wilkins
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Infectious Diseases in Clinical Practice
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Volume 20, Number 1, January 2012
TABLE 1. Specific Situations Where Antibiotics Should
Be Withheld
Respiratory tract syndromes
Viral pharyngitis10
Viral rhinosinusitis10
Viral bronchitis10
Noninfectious cardiopulmonary disorders misdiagnosed
as pneumonia
AOM (for selected cases, refer to article)22
SSTIs
Subcutaneous abscesses (for selected cases, refer to article)26
Lower extremity stasis dermatitis29
Asymptomatic bacteriuria and pyuria, including
catheterized patients30,34
Microbial colonization and culture contamination36
Low-grade fever41
identified or at least suspected, the regimen should be deescalated.4 On the other hand, although the presence of bacteria
may, of course, signal infection and merit antibiotics, colonization is natural and should not be treated. The problem is distinguishing one from the other. Cultures need to be evaluated
in their clinical setting. For example, bacteriuria in a patient
who is asymptomatic represents colonization and should not be
treated.30,34
There are few studies examining the duration of antibiotic
therapy. With the exception of streptococcal pharyngitis (10 days
of penicillin V) and prolonged courses for infectious endocarditis and osteomyelitis, for example, duration is remarkably arbitrary.5 Yet, it is not without staunch proponents. Observational
studies, expert opinion, conventional wisdom, and round numbers such as 5, 7, 10, and 14 days are often proposed dogmatically, albeit without evidence or physiologic rationale. Duration
of therapy should be individualized. Serial measurements of inflammation markers such as the erythrocyte sedimentation rate
and C-reactive protein and procalcitonin levels have some value
in helping decide when an infection has resolved and antibiotics
can be discontinued, although these lack complete specificity and
sensitivity.44 Normalization of a patient’s temperature and white
blood cell count remain the standard and most physiologic indicators to discontinue antibiotics, although their predictive value
is also imperfect. Difficult clinical decisions must not be oversimplified. When uncertain, for patients initially treated with IV
antibiotics, a compromise in duration is a po substitution.4 It is
predicated on a patient’s clinical improvement, an acceptable po
alternative, and a functioning gastrointestinal tract. However, if
the patient is doing well clinically, we believe that consideration
should be given to discontinuing antibiotics altogether. Shorter
durations may be as effective as longer ones and may lead to less
MDRO and CDI. Although the ideal duration of antibiotics
remains uncertain in most cases and needs more study, practice
guidelines for several infections are progressing and are summarized in this article.
There are several obstacles confronting the implementation
of ABS. First, there is apparent unfamiliarity with the specific
clinical guidelines to control antibiotic overuse. The Centers for
Disease Control address this with their programs.11 Furthermore,
the goal of this article is to facilitate implementation by cataloging
and summarizing these guidelines. Second, even when recognized, there is incomplete acceptance of the guideline recommendations. Khan et al45 and Lee et al46 have pointed out that
* 2012 Lippincott Williams & Wilkins
Antibiotic Stewardship
many of the recommendations are based on low-quality evidence.
In their reviews, only 16% and 14%, respectively, are based on
randomized clinical trials. A recently published study on hospitalacquired, ventilator-associated, and health careYassociated pneumonia reported that compliance with the IDSA/ATS Guidelines
resulted in increased mortality.47 However, as noted in the accompanying editorial,48 ‘‘the validity of [the] analysis is subject
to controversy.’’ The comparison groups were not equal in regards
to the risk for mortality. In particular, the guideline-compliant
group had a statistically higher incidence of sepsis (91% vs 76%),
had previously received antibiotics more frequently (75% vs
56%), and had lower antibiotic coverage of certain multidrugresistant pathogens (59% vs 94%). Furthermore, up to one half of
the guideline-compliant group failed to undergo appropriate deescalation of antibiotics based on the microbial results (ie, they
were actually in the nonYguideline-compliant group). In addition,
the comparison groups were not analyzed in regards to the timing
of antibiotics, a critical issue for sepsis.
Clearly, the guidelines are imperfect. In acknowledging
their imperfection, the IDSA/ATS CAP Guidelines, for example,
make the following statement: ‘‘Although these guidelines are
evidence based, the committee strongly urges that deviation from
them not necessarily be considered substandard care, unless they
are accompanied by evidence for worse outcomes in a studied
population.’’20 We need to be wary of unintended consequences.
We need more and better studies. Third, there is fear, by both
physicians and patients, that undertreatment, that is, withholding
or prematurely discontinuing antibiotics, will result in harm. Litigation may fuel these concerns. Intuition suggests that more is
better, but the correct balance remains uncertain. Indeed, clinical
medicine remains more of an art than a science in many situations,
and clinical uncertainty is common. Although using the recommendations summarized in this article should give physicians
confidence in their antibiotic restraint decisions, ABS needs to be
practiced with a healthy skepticism and conservatism. The principles and practice of ABS should not be overstated, and indiscriminate application of the guideline recommendations must be
avoided. Cases for interventions need to be selected carefully. To
counterbalance patients’ concerns, the negative consequences of
antibiotic overuse appear regularly in the press and are even satirized.49,50 The medical establishment needs to continue to popularize the drawbacks of antibiotic overuse. Furthermore, litigation
based on adverse reactions to antibiotic misuse is evolving and
acts as an additional counterbalance. Lastly, there is no clear
TABLE 2. Practice Guideline Recommendations Regarding
Duration of Therapy
CAP, 5 d20
Health careYacquired pneumonia, 8 d21
SSTI, 5 d28
UTI
Cystitis, 3-5d (depending on antibiotic)35
Pyelonephritis, 5Y14 d (depending on antibiotic)35
Catheter associated, 7 d
(prolonged to 10Y14 d for delayed response)34
S. aureus bacteremia
Low risk of complications, 2 wk37
High risk of complications, 4Y6 wk37
Intra-abdominal infection, 4Y7 d38
Surgical antibiotic prophylaxis, 1 dose
(up to 24 h, without exception)39,40
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mandate to enforce the ABS guidelines. This said, the Joint
Commission and CMS have made the surgical antibiotic prophylaxis recommendations mandatory.51 We believe that regulatory agencies should similarly promote antibiotic restraint. Gross
and Patel’s33 ‘‘call for a national performance measure for not
treating asymptomatic bacteriuria’’ is an excellent example of how
to proceed. Not interveningVallowing antibiotic overuse to
continue uncheckedVunnecessarily promotes the MDRO and
CDI epidemics.
13. Bisno AL, Gerber MA, Gwaltney JM Jr, et al. Practice guidelines for
the diagnosis and management of group A streptococcal pharyngitis.
Clin Infect Dis. 2002;35(2):113Y125.
CONCLUSIONS
16. Global strategy for the diagnosis, management, and prevention of
chronic lung disease [Global Initiative for Chronic Obstructive
Lung Disease Web site]. Available at: http://www.goldcopd.com/
Guidelineitem.asp?l1=2&l2=1&intId=2003. Accessed January 31, 2011.
Although the concept of ABS is not new, precisely when
to withhold and withdraw antibiotics from the practical point of
view has received relatively little attention. Its importance is punctuated by the MDRO and CDI epidemics. Implementing ABS by
using the clinical practice guidelines summarized in this article
should be promoted to quell the MDRO and CDI epidemics.
ACKNOWLEDGMENT
The authors thank Alice Engelbrecht, PharmD, clinical
pharmacist, Department of Pharmacy, Oklahoma University
Medical Center, Oklahoma City, OK.
REFERENCES
14. Rosenfeld RM, Andes D, Bhattacharyya N, et al. Clinical
practice guideline: adult sinusitis. Otolaryngol Head Neck Surg.
2007;137(suppl 3):S1YS31.
15. Sethi S, Murphy TF. Infection in the pathogenesis and course
of chronic obstructive pulmonary disease. N Engl J Med.
2008;359(22):2355Y2365.
17. Roede BM, Bresser P, El Moussaoui R, et al. Three vs. 10 days of
amoxicillin-clavulanic acid for type 1 acute exacerbations of chronic
obstructive pulmonary disease: a randomized, double-blind study.
Clin Microbiol Infect. 2007;13(3):284Y290.
18. National summary statistics for RHQDAPU clinical process measures
on hospital compare [Centers for Medicare and Medicaid Services Web
site]. Available at: http://www.cms.gov/HospitalQualityInits/downloads/
HospitalNationalLevelPerformance.pdf. Accessed April 11, 2011.
19. Welker JA, Huston M, McCue JD. Antibiotic timing and errors in
diagnosing pneumonia. Arch Intern Med. 2008;168(4):351Y356.
1. Spellberg B, Guidos R, Gilbert D, et al. The epidemic of
antibiotic-resistant infections: a call to action for the medical community
from the Infectious Diseases Society of America. Clin Infect Dis.
2008;46(2):155Y164.
20. Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases
Society of America/American Thoracic Society consensus guidelines
on the management of community-acquired pneumonia in adults.
Clin Infect Dis. 2007;44(suppl 2):S27YS72.
2. McDonald LC, Owings M, Jernigan DB. Clostridium difficile infection
in patients discharged from US short-stay hospitals, 1996Y2003.
Emerg Infect Dis. 2006;12(3):409Y415.
21. American Thoracic Society and 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):388Y416.
3. Sir Alexander FlemingVNobel Lecture [Nobel Prize Web site].
Available at: http://nobelprize.org/nobel_prizes/medicine/laureates/
1945/fleming-lecture.html. Accessed January 31, 2011.
4. Dellit TH, Owens RC, McGowan JE Jr, et al. Infectious Diseases
Society of America and the Society for Healthcare Epidemiology of
America guidelines for developing an institutional program to enhance
antimicrobial stewardship. Clin Infect Dis. 2007;44(2):159Y177.
22. American Academy of Pediatrics and American Academy of
Family Physicians. Clinical practice guideline on the diagnosis and
management of acute otitis media. Pediatrics. 2004;113(5):1451Y1465.
23. Tähtinen PA, Laine MK, Houvinen, P, et al. A placebo-controlled
trial of antimicrobial treatment for acute otitis media. N Engl J Med.
2011;364(2):116Y126.
5. Rice LB. The Maxwell Finland Lecture: for the duration-rational
antibiotic administration in an era of antimicrobial resistance
and Clostridium difficile. Clin Infect Dis. 2008;46(4):491Y496.
24. Hoberman A, Paradise JL, Rockette HE, et al. Treatment of
acute otitis media in children under 2 years of age. N Engl J Med.
2011;364(2):105Y115.
6. Gross R, Morgan AS, Kinky DE, et al. Impact of a hospital-based
antimicrobial management program on clinical and economic outcomes.
Clin Infect Dis. 2001;33(3):289Y295.
25. Klein JO. Is acute otitis media a treatable disease? N Engl J Med.
2011;364(2):168Y169.
7. Carling P, Fung T, Killion A, et al. Favorable impact of a
multidisciplinary antibiotic management program conducted during
7 years. Infect Control Hosp Epidemiol. 2003;24(9):699Y706.
26. Liu C, Bayer A, Cosgrove SE, et al. Clinical practice guidelines
by the Infectious Diseases Society of America for the treatment of
methicillin-resistant Staphylococcus aureus infections in adults
and children. Clin Infect Dis. 2011;52(3):1Y38.
8. Fowler S, Webber A, Cooper BS, et al. Successful use of feedback to
improve antibiotic prescribing and reduce Clostridium difficile infection:
a controlled interrupted time series. J Antimicrob Chemother.
2007;59(5):990Y995.
27. Jenkins TC, Sabel AL, Sarcone EE, et al. Skin and soft-tissue
infections requiring hospitalization at an academic medical center:
opportunities for antimicrobial stewardship. Clin Infect Dis.
2010;51(8):895Y903.
9. Huttner B, Harbarth S. ‘‘Antibiotics are not automatic anymore’’Vthe
French national campaign to cut antibiotic overuse. PLoS Med.
2009;6(6):e1000080.
28. Hepburn MJ, Dooley DP, Skidmore PJ, et al. Comparison of
short-course (5 days) and standard (10 days) treatment for
uncomplicated cellulitis. Arch Intern Med. 2004;164(15):1669Y1674.
10. Mandell GL, Bennett JE, Dolin R, eds. Principles and Practice of
Infectious Diseases. 7th ed. Philadelphia, PA: Elsevier Inc; 2010.
29. Weingarten MS. State-of-the-art treatment of chronic venous disease.
Clin Infect Dis. 2001;32(6):949Y954.
11. Get smart: know when antibiotics work [Centers for Disease Control
and Prevention Web site]. Available at: http://www.cdc.gov/getsmart/
campaign-materials/info-sheets/adult-approp-summary.html.
Accessed January 31, 2011.
30. Nicolle LE, Bradley S, Colgan R, et al. Infectious Diseases Society of
America guidelines for the diagnosis and treatment of asymptomatic
bacteriuria in adults. Clin Infect Dis. 2005;40(5):643Y654.
12. Linder JA, Stafford RS. Antibiotic treatment of adults with sore
throat by community primary care physicians: a national survey,
1989Y1999. JAMA. 2001;286(10):1181Y1186.
16
www.infectdis.com
31. Hospital-acquired conditions [Centers for Medicare and
Medicaid Services Web site]. Available at: http://www.cms.gov/
HospitalAcqCond/06_Hospital-Acquired Conditions.asp.
Accessed January 31, 2011.
* 2012 Lippincott Williams & Wilkins
Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Infectious Diseases in Clinical Practice
&
Volume 20, Number 1, January 2012
32. Screening for asymptomatic bacteriuria in adults: US Preventive
Services Task Force reaffirmation recommendation statement.
AHRQ Publication No. 08-05120-EF-1, 2008 [US Preventive
Services Task Force Web site]. Available at: http://
www.uspreventiveservicestaskforce.org/uspstf08/asymptbact/
asbactrs.htm. Accessed April 11, 2011.
33. Gross PA, Patel B. Reducing antibiotic overuse: a call for a national
performance measure for not treating asymptomatic bacteriuria.
Clin Infect Dis. 2007;45(10):1335Y1337.
34. Hooton TM, Bradley SF, Cardenas DD, et al. Diagnosis, prevention,
and treatment of catheter-associated urinary tract infection in
adults: 2009 international clinical practice guidelines from
the Infectious Diseases Society of America. Clin Infect Dis.
2010;50(5):625Y663.
35. Gupta K, Hooton TM, Naber KG, et al. Guidelines for antimicrobial
treatment of uncomplicated acute bacterial cystitis and acute
pyelonephritis in women. Clin Infect Dis. 2011;52(5):e103Ye120.
36. Mermel LA, Allon M, Bouza E, et al. Clinical practice guidelines
for the diagnosis and management of intravascular catheter-related
infection: 2009 update by the Infectious Diseases Society of America.
Clin Infect Dis. 2009;49(1):1Y45.
37. Fowler VG Jr, Olsen MK, Corey GR, et al. Clinical identifiers of
complicated Staphylococcus aureus bacteremia. Arch Intern Med.
2003;163(17):2066Y2072.
38. Solomkin JS, Mazuski JE, Bradley JS, et al. Diagnosis and
management of complicated intra-abdominal infection in adults
and children: guidelines by the Surgical Infection Society and
the Infectious Diseases Society of America. Clin Infect Dis.
2010;50(2):133Y164.
39. Bratzler DW, Houck PM. Antimicrobial prophylaxis for surgery:
an advisory statement from the National Surgical Infection Prevention
Project. Clin Infect Dis. 2004;38(12):1706Y1715.
40. American Society of Health-System Pharmacists, Infectious Disease
Society of America, Surgical Infection Society, and Society of
Healthcare Epidemiology of America. Draft: therapeutic guidelines
on antimicrobial prophylaxis in surgery section: executive summary,
2010 [American Society of Health System Pharmacists Web site].
Available at: http://www.ashp.org/DocLibrary/Policy/
PracticeResources/ExecSummary-ForPublicComments.aspx.
Accessed April 11, 2011.
* 2012 Lippincott Williams & Wilkins
Antibiotic Stewardship
41. Mackowiak PA, Wasserman SS, Levine MM. A critical appraisal
of 98.6 degrees F, the upper limit of the normal body temperature,
and other legacies of Carl Reinhold August Wunderlich. JAMA.
1992;268(12):1578Y1580.
42. Freifeld AG, Bow EJ, Sepkowitz KA, et al. Clinical practice guideline
for the use of antimicrobial agents in neutropenic patients with
cancer: 2010 update by the Infectious Diseases Society of America.
Clin Infect Dis. 2011;52(4):e56Ye93.
43. Gandhi TN, DePestel DD, Collins CD, et al. Managing
antimicrobial resistance in intensive care units. Crit Care Med.
2010;38(suppl 8):S315YS323.
44. Schuetz P, Christ-Crain M, Thomann R, et al. Effect of
procalcitonin-based guidelines vs standard guidelines on antibiotic
use in lower respiratory tract infections: the ProHOSP randomized
controlled trial. JAMA. 2009;302(10):1059Y1066.
45. Khan AR, Khan S, Zimmerman V, et al. Quality and strength of
evidence of the Infectious Diseases Society of America clinical
practice guidelines. Clin Infect Dis. 2010;51(10):1147Y1156.
46. Lee DH, Vielemeyer O. Analysis of overall level of evidence
behind Infectious Diseases Society of America practice guidelines.
Arch Intern Med. 2011;171(1):18Y22.
47. Kett DH, Cano E, Quartin A, et al. Implementation of guidelines for
management of possible multidrug-resistant pneumonia in intensive
care: an observational, multicentre cohort study. Lancet Infect Dis.
2011;11(3):181Y189.
48. Ewig S. Nosocomial pneumonia: de-escalation is what matters.
Lancet Infect Dis. 2011;11(3):155Y157.
49. Stevens M. Don’t forget to take a handful of our complimentary
antibiotics on your way out. 1989. Available at: http://
www.cartoonbank.com/1998/dont-forget-to-take-a-handful-of-ourcomplimentary-antibiotics-on-your-way-out/invt/116765/.
Accessed April 11, 2011.
50. Morris G. When antibiotics stop working: magic bullets under
siege. 2000. Available at: http://www.cspinet.org/nah/5_00/
magicbullets.htm. Accessed April 11, 2011.
51. Centers for Medicare and Medicaid Services. Hospital inpatient quality
reporting program [Centers for Medicare and Medicaid Services
Web site]. Available at: http://www.cms.gov/HospitalQualityInits/
08_HospitalRHQDAPU.asp#TopOfPage. Accessed April 22, 2011.
www.infectdis.com
Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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