Blog | Thursday, May 12, 2016

Not just another guideline

The updated antibiotic stewardship guideline has been released, and is available at the Clinical Infectious Diseases website, and in pocket card and mobile versions. While the guideline will undoubtedly be essential for those tasked with establishing and running stewardship programs, it isn't going to be frequently referenced by prescribers.

Instead, treatment guidelines for specific clinical syndromes are more likely to guide prescribing decisions, either by direct application or via their incorporation into facility specific practice guidelines or CMS measures. Thus the impact of the stewardship guideline will be limited unless stewardship principles are also incorporated into treatment guidelines, pathways, and quality measures. This point was made in a recent editorial by Brad Spellberg, Arjun Srinivasan and Chip Chambers, and I know that HICPAC plans to summarize the stewardship principles that should be incorporated into all ID-related treatment guidelines.

Ensuring that antibiotic stewardship principles are considered carefully when infection-related quality measures are established is a continuing challenge—once a measure is tied to payment and/or public reporting, the law of unintended consequences takes over, including consequences for antibiotic use. We learned this with the ill-fated “4-hour rule” for treatment of community acquired pneumonia, which likely led to an untold number of inappropriate antibiotic doses andC. difficile cases, and we're struggling with it again around the new sepsis measure.

Finally, truly informed stewardship awaits a lot of research and development progress: to better establish dose and duration of therapy for common conditions, to improve diagnostics to allow more rapid directed therapy, as well as improved capacity to distinguish bacterial, fungal and viral etiologies, to more precisely determine the relative impact of different antibiotics on host microbiota (and the implications thereof), etc., etc., etc. Someday, I hope, we'll be able to look back at the 2016 guideline and marvel at how rudimentary it is—for now, though, it's excellent, so go read it!

Daniel J. Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. This post originally appeared at the blog Controversies in Hospital Infection Prevention.