Policy and Position Statements

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Antimicrobial Resistance and Stewardship Position Statement

Many once manageable diseases caused by bacteria are becoming increasingly resistant to the drugs that were designed to kill them. Some microbes have become resistant to many or even all classes of antibiotics currently on the market. Antibiotic resistance is one of the world's most pressing public health problems, responsible for more than 2 million illnesses and 23,000 deaths annually in the United States. CDC's report Antibiotic resistance threats in the United States, 2013 "gives a first-ever snapshot of the burden and threats posed by the antibiotic-resistant germs having the most impact on human health." The report notes that when antibiotics are rendered ineffective by resistance, alternatives are often more toxic, more expensive, and less effective. It also includes suggested actions state health agencies, working with other groups at the national, state, and local levels, can take to detect, control, and prevent the spread of resistant organisms.

An ongoing public health commitment is needed to halt the progression of antibiotic resistance, including sound surveillance methods; effective education of physicians, pharmacists, other healthcare workers, and the public regarding antibiotic resistance and appropriate use of antibiotics; and stable funding streams for federal, state, and local health agencies. Adequate resources are required for sustained and improved capacity to track antimicrobial use and resistance across all sectors, including agriculture. Without appropriate action, treatment options for certain infections will become more limited as resistance spreads; in some cases (such as multidrug-resistant organisms), alternative treatment options may not be available.

State health agencies play a role in addressing resistance because they are responsible for protecting patients across the healthcare system and serve as a bridge between healthcare organizations and the community (healthcare organizations include, but are not limited to, hospitals, outpatient medical centers, ambulatory care centers, long-term care facilities, and doctors' offices). State health agency roles in addressing antimicrobial resistance include preventing infections and protecting patients across the healthcare system (e.g., through immunization or food safety), tracking where infections are occurring and where antimicrobial resistance is growing (surveillance), and promoting appropriate antimicrobial prescribing and use (stewardship).

Antimicrobial stewardship programs help ensure that patients get the right antibiotics at the right time for the right duration. Stewardship programs can improve individual patient outcomes, prevent deaths from resistant infections, slow antibiotic resistance and decrease Clostridium difficile infections, and reduce healthcare costs.

New initiatives at CDC will provide expanded capacity to address infectious disease outbreaks and resistant pathogens. The Detect and Protect Against Antibiotic Resistance Initiative will speed up outbreak detection, support development of new antibiotics and diagnostics, and improve infection prevention and antibiotic prescribing. The Advanced Molecular Detection (AMD) Initiative will enhance CDC's microbiology and bioinformatics capabilities to find and stop infectious disease outbreaks.

An adequately resourced system is needed for effective infection control and surveillance, standardized reporting, improved antibiotic prescribing, and research for new ways to address resistance. Within this context, ASTHO supports the following (under the categories outlined in CDC's Four Core Actions to Prevent Antibiotic Resistance):

Preventing Infections, Preventing the Spread of Resistance

  • Coordination among federal, state, tribal, and local governments and private industry to promote effective infection control measures within the community.
  • Promotion of infection control protocols across the healthcare spectrum.
  • Use of surveillance data to describe the patterns of resistance so that action can be directed at preventing transmission.

Tracking

  • Surveillance for antibiotic-resistant organisms in healthcare settings and in the community to provide state-specific data. A systems approach is needed, including standardized definitions and reporting mechanisms and consistency in state reporting policies. With adequate capacity, epidemiologists can analyze surveillance data and create reports for stakeholders. Surveillance information and prescribing guidelines should be readily available to clinicians.
  • Monitoring of antimicrobial use in healthcare settings.
  • Routine, laboratory-based susceptibility testing and monitoring to identify emerging resistance patterns as they occur (e.g., testing to identify mechanisms of resistance). State labs need adequate capacity to accurately identify organisms and ensure data quality. ASTHO also supports collecting and publishing antibiograms (i.e., cumulative susceptibility report) and use of the National Healthcare Safety Network's Antimicrobial Use and Resistance module to help inform clinical decision making. State health agencies also may assist with analysis of antibiogram data.
  • Reinforcing state health agency involvement in reporting activities between federal, local, and healthcare agencies to strengthen the relationship between epidemiology and patient safety.
  • Electronic laboratory reporting to promote real time exchange of surveillance data between federal, state, and hospital laboratories, and with local, state, and federal public health agencies.
  • Monitoring patterns of antibiotic use in agriculture and enhancing collaboration between state health agencies (specifically public health veterinarians) and agricultural agencies to support appropriate antibiotic use in agriculture. Additionally, ASTHO supports increased research on the impact of antibiotic use in agriculture on human health.

Improving Antibiotic Prescribing/Stewardship

  1. Increase patient adherence to prescribed antibiotics.
  2. Decrease patient demand for antibiotics when they have illnesses for which antibiotics are not indicated.
  3. Promote judicious use of antibiotics among prescribers via medical school, residency, and other healthcare professional training programs, as well as in continuing education.
  4. Continue education for the public and healthcare providers on the benefits of hand hygiene, immunization, and other individual health behaviors that reduce risk of infection.
  • Analyzing prescribing data to identify the proportion of prescriptions that are appropriately or inappropriately prescribed (i.e., in the absence of laboratory confirmation, determining whether standard prescribing guidelines on appropriate use were followed).
  • Sharing best practices in use of electronic medical records and integration of pharmacy and microbiology information technology systems to support decision making related to optimal prescribing of antimicrobials.

Developing New Drugs and Diagnostic Tests

  • Developing rapid diagnostic and susceptibility tests as well as state-of-the-art laboratory techniques to effectively identify infections to ensure the patient is given appropriate treatment.
  • Identifying and defining best practices for antibiotic resistance control programs.
  • Creating systems that would augment the capacity of laboratories and public health agencies to monitor antibiotic resistance.
  • Ensuring new drugs are used appropriately (and not excessively) to preserve their effectiveness, (e.g., developing the ability to incorporate and monitor use of new antimicrobial drugs in antibiotic use surveillance systems).

Approval History:

ASTHO Position Statements relate to specific issues that are time sensitive, narrowly defined, or are a further development or interpretation of ASTHO policy. Statements are developed and reviewed by appropriate Policy Committees and approved by the ASTHO Executive Committee. Position Statements are not voted on by the full ASTHO membership.

Infectious Disease Policy Committee Review and Approval: May 2014
Board of Directors Review and Approval: July 2014

Statement Expires: 2017

For further information about this Position Statement, please contact ASTHO Infectious Disease Policy staff at infectious@astho.org.