Review
Ten key points for the appropriate use of antibiotics in hospitalised patients: a consensus from the Antimicrobial Stewardship and Resistance Working Groups of the International Society of Chemotherapy

https://doi.org/10.1016/j.ijantimicag.2016.06.015Get rights and content

Highlights

  • The misuse of antibiotics and its related bacterial resistance is a growing concern that deserves a wide variety of interventions.

  • Education of prescribers using these ten key points seems an essential initiative.

  • This 10 key points would guide prescribers to a better use of antibiotics, as one necessary step to tackle antimicrobial resistance.

Abstract

The Antibiotic Stewardship and Resistance Working Groups of the International Society for Chemotherapy propose ten key points for the appropriate use of antibiotics in hospital settings. (i) Get appropriate microbiological samples before antibiotic administration and carefully interpret the results: in the absence of clinical signs of infection, colonisation rarely requires antimicrobial treatment. (ii) Avoid the use of antibiotics to ‘treat’ fever: use them to treat infections, and investigate the root cause of fever prior to starting treatment. (iii) Start empirical antibiotic treatment after taking cultures, tailoring it to the site of infection, risk factors for multidrug-resistant bacteria, and the local microbiology and susceptibility patterns. (iv) Prescribe drugs at their optimal dosing and for an appropriate duration, adapted to each clinical situation and patient characteristics. (v) Use antibiotic combinations only where the current evidence suggests some benefit. (vi) When possible, avoid antibiotics with a higher likelihood of promoting drug resistance or hospital-acquired infections, or use them only as a last resort. (vii) Drain the infected foci quickly and remove all potentially or proven infected devices: control the infection source. (viii) Always try to de-escalate/streamline antibiotic treatment according to the clinical situation and the microbiological results. (ix) Stop unnecessarily prescribed antibiotics once the absence of infection is likely. And (x) Do not work alone: set up local teams with an infectious diseases specialist, clinical microbiologist, hospital pharmacist, infection control practitioner or hospital epidemiologist, and comply with hospital antibiotic policies and guidelines.

Introduction

Antibiotic resistance is significantly increasing. Recently, the World Health Organization (WHO) [1], the US Centers for Disease Prevention and Control (CDC), the European Centre for Disease Control and Prevention (ECDC) [2], a UK report [3] and a US White House document [4] highlighted it as a major public health crisis. This camecoincidentally with the call for financial ‘incentives’ to encourage the pharmaceutical industry to return to the search for new antibiotics [5].

Whilst some mechanisms of antimicrobial resistance can be traced back to ancient bacteria [6], evidence—although scarce—indicates that it was rare in clinical isolates from the ‘pre-antibiotic era’ [7]. Moreover, whilst there are many studies correlating antimicrobial usage and the emergence of resistance [8], other societal factors, such as corruption [9], also play a significant role.

In 2011, the Antimicrobial Stewardship Working Group of the International Society of Chemotherapy (ISC) published the ‘10 Commandments’ for the appropriate use of antibiotics in the outpatient setting [10]. The present Ten Key Points—named so to avoid religious undertones that might prevent a wider reach for these recommendations—are targeted to healthcare workers in hospitals. Many of these key points were included in a revision of quality indicators for measuring appropriateness of antibiotic use to treat infections in hospitalised adult patients [11]. Also, a well-designed ‘Day 3 bundle’ to improve the re-assessment of inpatient empirical antibiotic prescriptions [12] included some of these concepts.

This consensus summarises the key issues regarding the rational use of antibiotics in hospitalised patients. The aim is to provide essential concepts that should be kept in mind to improve overall antibiotic management in these settings.

Section snippets

Methodology

This consensus was achieved by clinical microbiologists and infectious diseases (ID) physicians for the ISC Antimicrobial Stewardship Working Group.

Initially, the group agreed on defining the ten key points and the main issues to be discussed in each one, followed by a revision of original articles and guidelines related to every key point identified through MEDLINE, EMBASE, LILACS, Cochrane Library and different websites up to April 2016. The manuscript was circulated four times for discussion

Final considerations

The non-clinical use of antibiotics and their massive release into the environment may exert the most relevant pressure in the emergence and selection of resistant bacteria [93]. However, there are important ‘hotspots’ where pathogenic bacteria and huge amounts of various antibiotics coincide, fostering resistance emergence, exchange of resistance genes and their spread. Hospitals are among such hotspots. From the clinical point of view, we are now facing the threat of a lack of effective

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