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7 Steps to Be a Good Antibiotic Steward

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Protecting our natural resources for future generations is our duty. Our children have the right to inherit an unspoiled planet with plenty of food, water supplies, minerals, and clean air. What we take for granted today may affect the future generations for years to come.

Antibiotics are no different. They are precious resources that we possess and they need to be treated as such. Overuse of antibiotics is a leading cause of drug resistant bacteria. According to CDC, 1 in 3 antibiotic prescriptions are unnecessary. This is unacceptable.

Antibiotics are responsible from a long list of complications including clostridium difficile associated diarrhea, kidney or liver failure, drug-drug interactions, GI side effects, QTc prolongation, hospital readmissions, millions of dollars lost in health care, and unquantifiable losses for the patients who experience these complications.

As an infectious diseases specialist, I have the privilege of leading antibiotic stewardship activities, also teaching and interacting with colleagues, residents, students and nurses on a daily basis. I am also aware that there are many colleagues from various walks of medicine who don’t have access to that type of service or environment.

Here are some basic, key elements of antibiotic stewardship that I hope will help you be better antibiotic stewards. These principles can also be applied to other antimicrobials, including anti-virals and anti-fungals.

  1. Does my patient really need an antibiotic? First and most important step: assess the situation. Do you have high suspicion for a bacterial infection? Every fever or cold does not require prescription of antibiotics. Resist the knee-jerk reflex. Think before you give antibiotics. Educate your patient if you don’t think antibiotics are needed.
  2. Did I give the correct antibiotic for the diagnosis that I suspected? Assuming you are suspecting a bacterial infection at this point, make sure you have not chosen an antibiotic that is not indicated for the particular diagnosis you have in mind. Also, under this bullet is "Do not overshoot." For example, if you are treating a strep throat, treat the streptococcus only. No need to give unnecessary broad spectrum coverage. Remember, you need to preserve the precious antibiotics and prevent unnecessary complications. If you are not sure of the type of antibiotic needed, do the research. Don’t guess or prescribe a broad spectrum antibiotic instead.
  3. Did I dose the antibiotic correctly? Particularly if your patient has kidney or liver failure, antibiotics may need to be dose adjusted. You may not know the adjusted dose for every antibiotic for liver or kidney failure by heart and you don’t have to. Make sure to think about it when you prescribe the antibiotic and look up the dosing from reliable resources if needed. Pharmacists are your friends. You can always ask them help you with dosing. This would also save you from getting a phone call from the pharmacist if you order an incorrect dose, that is if you are lucky enough that a pharmacist recognizes it before the prescription is filled.
  4. Did I order the necessary testing for the suspected diagnosis? Make sure to order the necessary lab testing ideally before you start the antibiotics, i.e. blood cultures, sputum culture, urine culture, chest x-ray, CBC, and a basic metabolic panel. Do not assume that broad spectrum antibiotics give you a pass lab testing, they don’t.
  5. Did you reassess your antibiotics in 24–48 hours? Do not start antibiotics then forget about them. Questions to ask every day: How is the patient doing? Any side effects from antibiotics? Check your patient and the labs; determine if there is a need to de-escalate (yes, a military term, we are at war with drug resistance!), change, escalate, or discontinue the antibiotics. Maybe now you have evidence that the patient’s initial presentation was due to congestive heart failure and not a pneumonia. Discontinue unnecessary antibiotics.
  6. Does my patient still need IV antibiotics? Except for certain situations, most patients can be treated with oral antibiotics. Switch to oral antibiotics as soon as you can safely do so. In general, if your patient is on a po diet or if he/she is taking other oral medications, then you can switch to oral antibiotics unless there is a compelling reason not to do so.
  7. How long am I going to treat this infection? Try to have a sense of your total antibiotic treatment course as soon as you can. This may become apparent a day or two after diagnosis with the lab results or patient’s clinical progression, or right at the same time you see the patient you might know how long antibiotics will be needed. Most of us are using electronic health records when placing orders, so if you know the duration of antibiotics for your patient, put a stop date for the antibiotics in the orders. This would prevent inadvertently continuing the antibiotics longer than necessary.

Lastly, if you need help, call ID if you have ID consultation services available to you at your facility.

We are all antibiotic stewards and we need to utilize antibiotics responsibly.

Gul Madison, MD, is an infectious diseases specialist in Philadelphia. She is also a 2018–19 Doximity Author.

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