Antimicrobial Stewardship Programs: Effects on Clinical and Economic Outcomes and Future Directions

Another area of focus for future ASPs is the use of rapid diagnostics. Currently, when patients present with signs and symptoms of an infection, an empiric antimicrobial regimen is started that is then de-escalated as necessary; rapid testing will help to initiate appropriate therapy more quickly and increase antimicrobial effectiveness. Rapid tests range from rapid polymerase chain reaction (PCR)-based screening [50], to Verigene gram-positive blood culture (BC-GP) tests [51], next-generation sequencing methods, and matrix assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS) [52]. Rapid diagnostic tools should be viewed as aides to assist ASPs in decreasing antibiotic consumption and improving patient outcomes; these various tools have been shown to improve clinical outcomes when integrated into ASPs, but offer little value addressing the goals of ASPs when used outside of stewardship programs and their sensitive timeframes [53].

In terms of future ASP expansion, stewardship implementation can become more unified and broad in scope. ASPs should expand to include antifungal interventions, an area which is showing progress [36]. ASPs can also be implemented in new areas throughout the hospital (eg, pediatrics and emergency room), as well as areas outside of the hospital setting, including long-term care facilities, dialysis centers, and other institutions [54–56]. A prospective randomized control study was conducted in 30 nursing homes to evaluate the use of a novel resident antimicrobial management plan (RAMP) for improved use of antimicrobials [57]. This study found that the RAMP had no associated adverse effects and suggests that ASP is an important tool in nursing homes. In addition, the general outpatient and pediatric settings show promise for ASPs [56,58,59], but more research is needed to support expansion and to identify how ASP interventions should be applied in these various practice settings. The antimicrobial stewardship interventions that will be utilized will need to be carefully delineated to consider the scale, underlying need, and potential challenges in those settings.

While the future of antibiotic stewardship is unclear, there is certainty that it will continue to develop in both scope and depth to encompass new areas of focus, new settings to improve outcomes, and employ new tools to refine approaches. An important first step for the continued development of ASPs is alignment and standardization, since without alignment it will continue to be difficult to compare outcomes. This issue is currently being addressed by a number of different organizations. With current support from the Joint Commission, the CDC, as well as the President’s Council of Advisors on Science and Technology (PCAST) [8], regulatory requirements for ASPs are well underway, and these drivers will appropriately position ASPs for further advancements. By reducing variability amongst ASPs and delineating implementation of ASPs, there can be a clear identification of both economic and clinical benefits associated with specific interventions.

Corresponding author: Luigi Brunetti, PharmD, MPH, Rutgers, The State University of New Jersey, 160 Frelinghuysen Rd., Piscataway, NJ 08854, brunetti@pharmacy.rutgers.edu.

Financial disclosures: None.