Skip to main content

Advertisement

SpringerLink
Log in

Antimicrobial Stewardship Programs: A Review of Recent Evaluation Methods and Metrics

  • Antimicrobial Stewardship (AL Pakyz, Section Editor)
  • Published:
Current Treatment Options in Infectious Diseases Aims and scope Submit manuscript

Opinion statement

There is a growing body of literature on the effectiveness of Antimicrobial Stewardship programs (ASPs). A review of recent ASP literature demonstrates a wide variety of study designs and methods of evaluation. Valid, careful and scientifically rigorous program evaluations will fortify the stewardship evidence base, and teach us all how to best maximize the benefits and minimize the harms of antimicrobial treatments.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References and Recommended Reading

Papers of particular interest, published recently, have been highlighted as: • Of importance

  1. Dellit TH 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):159–77.

    Article  PubMed  Google Scholar 

  2. Nicolle L et al. Antimicrobial Use in Long -Term- Care Facilities. Infect Control Hosp Epidemiol. 2000;21(8):9.

    Article  Google Scholar 

  3. Required Organizational Practices Handbook 2013, A. Canada, Editor. 2013, Accreditation Canada: Ottawa. Available at http://www.accreditation.ca/publications-menu.

  4. Elligsen M et al. Prospective audit and feedback of antimicrobial stewardship in critical care: program implementation, experience, and challenges. Can J Hosp Pharm. 2012;65(1):31–6.

    PubMed Central  PubMed  Google Scholar 

  5. Neuman MI et al. Influence of hospital guidelines on management of children hospitalized with pneumonia. Pediatrics. 2012;130(5):p. e823–30.

    Article  Google Scholar 

  6. Wong JR et al. Antimicrobial stewardship pharmacist interventions for coagulase-negative staphylococci positive blood cultures using rapid polymerase chain reaction. Ann Pharmacother. 2012;46(11):1484–90.

    Article  PubMed  Google Scholar 

  7. Standiford HC et al. Antimicrobial stewardship at a large tertiary care academic medical center: cost analysis before, during, and after a 7-year program. Infect Control Hosp Epidemiol. 2012;33(4):338–45.

    Article  PubMed  Google Scholar 

  8. Liew YX et al. Impact of an antimicrobial stewardship programme on patient safety in Singapore General Hospital. Int J Antimicrob Agents. 2012;40(1):55–60.

    Article  CAS  PubMed  Google Scholar 

  9. Vettese N et al. Outcomes associated with a thrice-weekly antimicrobial stewardship programme in a 253-bed community hospital. J Clin Pharm Ther. 2013;38(5):401–4.

    Article  CAS  PubMed  Google Scholar 

  10. Nowak MA et al. Clinical and economic outcomes of a prospective antimicrobial stewardship program. Am J Health Syst Pharm. 2012;69(17):1500–8.

    Article  PubMed  Google Scholar 

  11. Yam P et al. Implementation of an antimicrobial stewardship program in a rural hospital. Am J Health Syst Pharm. 2012;69(13):1142–8.

    Article  PubMed  Google Scholar 

  12. Rimawi RH et al. The impact of penicillin skin testing on clinical practice and antimicrobial stewardship. J Hosp Med. 2013;8(6):341–5.

    Article  PubMed  Google Scholar 

  13. Hermsen ED et al. Implementation of a clinical decision support system for antimicrobial stewardship. Infect Control Hosp Epidemiol. 2012;33(4):412–5.

    Article  PubMed  Google Scholar 

  14. Antworth A et al. Impact of an antimicrobial stewardship program comprehensive care bundle on management of candidemia. Pharmacotherapy. 2013;33(2):137–43.

    Article  PubMed  Google Scholar 

  15. NHMRC, A guide to the development, implementation and evaluation of clinical practice guidelines. Canberra, ACT: National Health and Medical Research Council, Commonwealth of Australia, 1999.

  16. Merlin T, Weston A, Tooher R. Extending an evidence hierarchy to include topics other than treatment: revising the Australian 'levels of evidence'. BMC Med Res Methodol. 2009;9:34–41.

    Article  PubMed Central  PubMed  Google Scholar 

  17. Pate PG, Storey DF, Baum DL. Implementation of an antimicrobial stewardship program at a 60-bed long-term acute care hospital. Infect Control Hosp Epidemiol. 2012;33(4):405–8.

    Article  PubMed  Google Scholar 

  18. Boyce JM et al. A trial of discontinuation of empiric vancomycin therapy in patients with suspected methicillin-resistant Staphylococcus aureus health care-associated pneumonia. Antimicrob Agents Chemother. 2013;57(3):1163–8.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  19. Avdic E et al. Impact of an antimicrobial stewardship intervention on shortening the duration of therapy for community-acquired pneumonia. Clin Infect Dis. 2012;54(11):1581–7.

    Article  PubMed  Google Scholar 

  20. Malani AN et al. Clinical and economic outcomes from a community hospital's antimicrobial stewardship program. Am J Infect Control. 2013;41(2):145–8.

    Article  PubMed  Google Scholar 

  21. Coll A, Kinnear M, Kinnear A. Design of antimicrobial stewardship care bundles on the high dependency unit. Int J Clin Pharm. 2012;34(6):845–54.

    Article  PubMed  Google Scholar 

  22. Potasman I, Naftali G, Grupper M. Impact of a computerized integrated antibiotic authorization system. Isr Med Assoc J: Imaj. 2012;14(7):415–9.

    PubMed  Google Scholar 

  23. Angoulvant F et al. Impact of implementing French antibiotic guidelines for acute respiratory-tract infections in a paediatric emergency department, 2005-2009. Eur J Clin Microbiol Infect Dis. 2012;31(7):1295–303.

    Article  CAS  PubMed  Google Scholar 

  24. Newman RE et al. Impact of a guideline on management of children hospitalized with community-acquired pneumonia. Pediatrics. 2012;129(3):e597–604.

    Article  PubMed  Google Scholar 

  25. Gillespie E et al. Improving antibiotic stewardship by involving nurses. Am J Infect Control. 2013;41(4):365–7.

    Article  PubMed  Google Scholar 

  26. Wilde AM et al. Inappropriate antibiotic use due to decreased compliance with a ventilator-associated pneumonia computerized clinical pathway: implications for continuing education and prospective feedback. Pharmacother:J Human Pharmacol Drug Ther. 2012;32(8):755–63.

    Article  Google Scholar 

  27. Cosgrove SE et al. Evaluation of postprescription review and feedback as a method of promoting rational antimicrobial use: a multicenter intervention. Infect Control Hosp Epidemiol. 2012;33(4):374–80.

    Article  PubMed  Google Scholar 

  28. Nausheen S, Hammad R, Khan A. Rational use of antibiotics–a quality improvement initiative in hospital setting. J Pak Med Assoc. 2013;63(1):p. 60–4.

    Google Scholar 

  29. Niwa T et al. Outcome measurement of extensive implementation of antimicrobial stewardship in patients receiving intravenous antibiotics in a Japanese university hospital. Int J Clin Pract. 2012;66(10):999–1008.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  30. Lopez-Medrano F et al. A non-compulsory stewardship programme for the management of antifungals in a university-affiliated hospital. Clin Microbiol Infect. 2013;19(1):56–61.

    Article  CAS  PubMed  Google Scholar 

  31. Shrestha NK et al. Antimicrobial stewardship at transition of care from hospital to community. Inf Control Hosp Epidemiol. 2012;33(4):401–4.

    Article  Google Scholar 

  32. Yang YN et al. A strategy for reduction of antibiotic use in new patients admitted to a neonatal intensive care unit. Pediatr Neonatol. 2012;53(4):245–51.

    Article  PubMed  Google Scholar 

  33. Galar A et al. Clinical and economic evaluation of the impact of rapid microbiological diagnostic testing. J Infect. 2012;65(4):302–9.

    Article  CAS  PubMed  Google Scholar 

  34. Katsios CM et al. An antimicrobial stewardship program improves antimicrobial treatment by culture site and the quality of antimicrobial prescribing in critically ill patients. Crit Care. 2012;16(6):R216.

    Article  PubMed Central  PubMed  Google Scholar 

  35. Rimawi RH et al. Impact of regular collaboration between infectious diseases and critical care practitioners on antimicrobial utilization and patient outcome. Crit Care Med. 2013;41(9):2099–107.

    Article  PubMed  Google Scholar 

  36. Ulug M, Kemec O, Can Ulug N. The Efficacy of an Antibiotic Control Team on Rational Antibiotic Use: Cost-Utility Analysis and Achievement in Surgical Prophylaxis. Klimik Dergisi/Klimik J. 2012;25(1):p. 14–18.

    Article  Google Scholar 

  37. Dancer SJ et al. Approaching zero: temporal effects of a restrictive antibiotic policy on hospital-acquired Clostridium difficile, extended-spectrum beta-lactamase-producing coliforms and meticillin-resistant Staphylococcus aureus. Int J Antimicrob Agents. 2013;41(2):137–42.

    Article  CAS  PubMed  Google Scholar 

  38. Gugkaeva Z, Franson M. Pharmacist-led model of antibiotic stewardship in a long-term care facility. Ann Long-Term Care: Clin Care Aging. 2012;20(10):5.

    Google Scholar 

  39. Albrich WC et al. Effectiveness and safety of procalcitonin-guided antibiotic therapy in lower respiratory tract infections in "real life": an international, multicenter poststudy survey (ProREAL). Arch Intern Med. 2012;172(9):715–22.

    Article  CAS  PubMed  Google Scholar 

  40. Dryden M et al. Antibiotic stewardship and early discharge from hospital: impact of a structured approach to antimicrobial management. J Antimicrob Chemother. 2012;67(9):2289–96.

    Article  CAS  PubMed  Google Scholar 

  41. Gray A, Dryden M, Charos A. Antibiotic management and early discharge from hospital: an economic analysis. J Antimicrob Chemother. 2012;67(9):2297–302.

    Article  CAS  PubMed  Google Scholar 

  42. Mondain V et al. An antibiotic stewardship program in a French teaching hospital. Med Mal Infect. 2013;43(1):17–21.

    Article  CAS  PubMed  Google Scholar 

  43. Moorthy, R.K., H. Sarkar, and V. Rajshekhar, Conservative antibiotic policy in patients undergoing non-trauma cranial surgery does not result in higher rates of postoperative meningitis: An audit of nine years of narrow-spectrum prophylaxis. Br J Neurosurg, 2013.

  44. Reed EE et al. Impact of formulary restriction with prior authorization by an antimicrobial stewardship program. Virulence. 2013;4(2):158–62.

    Article  PubMed Central  PubMed  Google Scholar 

  45. Scawn N et al. A pilot randomised controlled trial in intensive care patients comparing 7 days’ treatment with empirical antibiotics with 2 days’ treatment for hospital-acquired infection of unknown origin. Health Technol Assess. 2012;16(36):1–75.

    Google Scholar 

  46. Layios N et al. Procalcitonin usefulness for the initiation of antibiotic treatment in.intensive care unit patients. Crit Care Med. 2012;40(8):p. 2304–9.

    Article  Google Scholar 

  47. Lesprit P, Landelle C, Brun-Buisson C. Clinical impact of unsolicited post-prescription antibiotic review in surgical and medical wards: a randomized controlled trial. Clin Microbiol Infect. 2013;19:p. E91–7. A rare randomized controlled trial to evaluate the impact of a complex antimicrobial stewardship intervention.

    Article  Google Scholar 

  48. Annane D et al. Procalcitonin levels to guide antibiotic therapy in adults with non-microbiologically proven apparent severe sepsis: a randomised controlled trial. BMJ Open. 2013;3:e002186.

    Article  PubMed Central  PubMed  Google Scholar 

  49. Ding J, Chen Z, Feng K. Procalcitonin-Guided Antibiotic Use in Acute Exacerbations of Idiopathic Pulmonary Fibrosis. Int J Med Sci. 2013;10(7):903–7.

    Article  PubMed Central  PubMed  Google Scholar 

  50. Aldeyab MA et al. An evaluation of the impact of antibiotic stewardship on reducing the use of high-risk antibiotics and its effect on the incidence of Clostridium difficile infection in hospital settings. J Antimicrob Chemother. 2012;67(12):2988–96.

    Article  CAS  PubMed  Google Scholar 

  51. Cairns KA et al. Prescribing trends before and after implementation of an antimicrobial stewardship program. Med J Aust. 2013;198(5):262–6.

    Article  PubMed  Google Scholar 

  52. Jump RL et al. Effective antimicrobial stewardship in a long-term care facility through an infectious disease consultation service: keeping a LID on antibiotic use. Infect Control Hosp Epidemiol. 2012;33(12):p. 1185–92. An interrupted time series examining the impact of antimicrobial stewardship in long term care, using hospital data as a control; also assessed the impact of seasonality and other important covariates, and accounted for multiple comparisons with Bonferroni adjustment.

    Article  Google Scholar 

  53. Magedanz L, Silliprandi EM, dos Santos RP. Impact of the pharmacist on a multidisciplinary team in an antimicrobial stewardship program: a quasi-experimental study. Int J Clin Pharm. 2012;34(2):290–4.

    Article  PubMed  Google Scholar 

  54. Teo J et al. The effect of a whole-system approach in an antimicrobial stewardship programme at the Singapore General Hospital. Eur J Clin Microbiol Infect Dis. 2012;31(6):947–55.

    Article  CAS  PubMed  Google Scholar 

  55. Yeo C et al. Prospective audit and feedback on antibiotic prescription in an adult hematology-oncology unit in Singapore. Eur J Clin Microbiol Infect Dis. 2012;31:583–90. An interrupted time series analysis utilizing external wards and controls, and paracetamol use as a tracer analysis.

    Article  PubMed  Google Scholar 

  56. Elligsen M et al. Audit and Feedback to Reduce Broad-Spectrum Antibiotic Use among Intensive Care Unit Patients: A Controlled Interrupted Time Series Analysis. Infect Control Hosp Epidemiol. 2012;33(4):p. 354–361. An interrupted time series analysis examining the impact of antimicrobial stewardship in ICU, using non-ICU wards as a control; also examined rates of gastric acid suppressor use as a tracer analysis.

  57. Guittet, L., P. Ravaud, and B. Giraudeau, Planning a cluster randomized trial with unequal cluster sizes: practical issues involving continuous outcomes. BMC medical research methodology, 2006. 6.

  58. Sibbald B, Roberts C. Understanding controlled trials. Crossover trials. BMJ Open. 1998;316(7146):1719.

    Article  CAS  Google Scholar 

  59. Hussey M, Hughes J. Design and analysis of stepped wedge cluster randomized trials. Contemp Clin Trials. 2007;28(2):182–91.

    Article  PubMed  Google Scholar 

  60. Handley M, Schillinger D, Shiboski S. Quasi-experimental designs in practice-based research settings: design and implementation considerations. J Am Board Fam Med. 2011;24(5):589–96.

    Article  PubMed  Google Scholar 

  61. Lilly C et al. Hospital mortality, length of stay, and preventable complications among critically ill patients before and after tele-ICU reengineering of critical care processes. JAMA :J Am Med Assoc. 2011;305(21):2175–83.

    Article  CAS  Google Scholar 

  62. Ciliberto M et al. Comparison of home-based therapy with ready-to-use therapeutic food with standard therapy in the treatment of malnourished Malawian children: a controlled, clinical effectiveness trial. Am J Clin Nutr. 2005;81(4):864–70.

    CAS  PubMed  Google Scholar 

  63. Somerville M et al. From local concern to randomized trial: the Watcombe Housing Project. Health Expect: Int J Publ Particip Health Care Health Policy. 2002;5(2):127–35.

    Article  Google Scholar 

  64. Fairley C et al. Randomized trial of an adherence programme for clients with HIV. Int J STD AIDS. 2003;14(12):805–9.

    Article  CAS  PubMed  Google Scholar 

  65. Levy R et al. Multidisciplinary HIV adherence intervention: a randomized study. AIDS Patient Care STDs. 2004;18(12):728–35.

    Article  CAS  PubMed  Google Scholar 

  66. Grant A et al. Effect of routine isoniazid preventive therapy on tuberculosis incidence among HIV-infected men in South Africa: a novel randomized incremental recruitment study. JAMA: J Am Med Assoc. 2005;293(22):2719–25.

    Article  CAS  Google Scholar 

  67. Priestley G et al. Introducing Critical Care Outreach: a ward-randomised trial of phased introduction in a general hospital. Intensive Care Med. 2004;30(7):1398–404.

    Article  PubMed  Google Scholar 

  68. Brown C et al. An epistemology of patient safety research: a framework for study design and interpretation. Part 2. Study design. Quality & safety in health care. 2008;17(3):163–9.

    Article  CAS  Google Scholar 

  69. Brown C, Lilford R. The stepped wedge trial design: a systematic review. BMC Med Res Methodol. 2006;6:54.

    Article  PubMed Central  PubMed  Google Scholar 

  70. Ramsay C et al. Interrupted time series designs in health technology assessment: lessons from two systematic reviews of behavior change strategies. Int J Technol Assess Health Care. 2003;19(4):613–23.

    Article  PubMed  Google Scholar 

  71. Fan E et al. How to use an article about quality improvement. JAMA: J Am Med Assoc. 2010;304(20):2279–87.

    Article  CAS  Google Scholar 

  72. Shojania KG. Conventional evaluations of improvement interventions: more trials or just more tribulations? BMJ Qual Saf. 2013;22(11):881–4.

    Article  PubMed  Google Scholar 

  73. Shekelle PG et al. Advancing the science of patient safety. Ann Intern Med. 2011;154(10):693–6.

    Article  PubMed  Google Scholar 

  74. Diaz Granados CA. Prospective audit for antimicrobial stewardship in intensive care: impact on resistance and clinical outcomes. Am J Infect Control. 2012;40(6):p. 526–9. Examined antimicrobial resistance at the patient level, and using a unified definition of clinically important antimicrobial resistant organisms; other strengths included an attempt to define antimicrobial appropriateness according to prespecified local guidelines, and use of multivariate logistic regression to account for important potential confounders.

    Article  Google Scholar 

  75. Liew YX et al. Utility and safety of procalcitonin in an antimicrobial stewardship program (ASP) in patients with malignancies. Eur J Clin Microbiol Infect Dis. 2012;31(11):3041–6.

    Article  CAS  PubMed  Google Scholar 

  76. Kim YC et al. Trend of methicillin-resistant Staphylococcus aureus (MRSA) bacteremia in an institution with a high rate of MRSA after the reinforcement of antibiotic stewardship and hand hygiene. Am J Infect Control. 2013;41(5):e39–43.

    Article  PubMed  Google Scholar 

  77. Kook JL et al. Impact of the use of procalcitonin assay in hospitalized adult patients with pneumonia at a community acute care hospital. Infect Control Hosp Epidemiol. 2012;33(4):424–6.

    Article  PubMed  Google Scholar 

  78. Hohn A et al. Procalcitonin-guided algorithm to reduce length of antibiotic therapy in patients with severe sepsis and septic shock. BMC Infect Dis. 2013;13:158.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  79. Burke JP. Antibiotic resistance–squeezing the balloon? Jama. 1998;280(14):1270–1.

    Article  CAS  PubMed  Google Scholar 

  80. Scawn N et al. A pilot randomised controlled trial in intensive care patients comparing 7 days' treatment with empirical antibiotics with 2 days' treatment for hospital-acquired infection of unknown origin. Health Technol Assess. 2012;16(36):1–70.

    Google Scholar 

  81. Beardsley JR et al. Show me the money: long-term financial impact of an antimicrobial stewardship program. Infect Control Hosp Epidemiol. 2012;33(4):398–400.

    Article  PubMed  Google Scholar 

  82. Ambroggio L et al. Quality improvement methods increase appropriate antibiotic prescribing for childhood pneumonia. Pediatrics. 2013;131(5):e1623–31.

    Article  PubMed Central  PubMed  Google Scholar 

  83. Litvin CB et al. Use of an electronic health record clinical decision support tool to improve antibiotic prescribing for acute respiratory infections: the ABX-TRIP study. J Gen Intern Med. 2013;28(6):810–6.

    Article  PubMed  Google Scholar 

Download references

Compliance with Ethics Guidelines

Conflict of Interest

Lesley Palmay, Sandra A.N. Walker, Jerome A. Leis, Linda R. Taggart, Colin Lee, and Nick Daneman declare no conflicts of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by the authors.

Author information

Authors and Affiliations

  1. Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, E-wing Room 233, Toronto, Ontario, M4N 3M5, Canada

    Lesley Palmay BSc.,BSc.Phm, MSc & Colin Lee BSc.Phm, PharmD

  2. Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, E-wing Room 302, Toronto, Ontario, M4N 3M5, Canada

    Sandra AN Walker BSc, BSc Phm, PharmD

  3. Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, H-wing, Room 463, Toronto, Ontario, M4N 3M5, Canada

    Jerome A. Leis MD, MSc, FRCPC

  4. St. Michael’s Hospital, 30 Bond Street, 4 Cardinal Carter North, Rm 4-179, Toronto, Ontario, M5B 1W8, Canada

    Linda R. Taggart MD, FRCPC

  5. Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, G-wing Room 106, Toronto, Ontario, M4N 3M5, Canada

    Nick Daneman MD, MSc, FRCPC

Authors
  1. Lesley Palmay BSc.,BSc.Phm, MSc
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Sandra AN Walker BSc, BSc Phm, PharmD
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Jerome A. Leis MD, MSc, FRCPC
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Linda R. Taggart MD, FRCPC
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Colin Lee BSc.Phm, PharmD
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Nick Daneman MD, MSc, FRCPC
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Nick Daneman MD, MSc, FRCPC.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Palmay, L., Walker, S.A., Leis, J.A. et al. Antimicrobial Stewardship Programs: A Review of Recent Evaluation Methods and Metrics. Curr Treat Options Infect Dis 6, 113–131 (2014). https://doi.org/10.1007/s40506-013-0008-7

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s40506-013-0008-7

Keywords

Search

Navigation