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With the discovery of penicillin, antibiotics are a critical part of global health, including cancer chemotherapy and advanced surgical procedures. Antimicrobial agents are not like other drugs. They are unique in that both the individual patient and the broader society bear the consequences of their use with each prescription. The antimicrobial effect that saves lives also exerts selective pressure on replicating bacteria, leading to the emergence of drug resistance. Between 1935 and 2003, fourteen new classes of antibiotics were introduced. Since 1998, only ten new antibiotics were approved, of which only linezolid and daptomycin have new targets of action.[1] According to the World Health Organization(WHO), antibiotic pipeline data report 2021, and eleven new antibiotics have been approved since 2017. Only two of them represent a new class and have a new target of action. They include vaborbactam+meropenem and lefamulin. The likely reason behind this is that the development of antibiotics is risky, expensive, and less profitable than the drugs to treat chronic diseases. With the slow development of antimicrobials, accelerated emergence, and spread of resistant organisms, antimicrobial stewardship is of utmost importance to optimize the use of existing antimicrobials.[1] Stewardship describes the careful and responsible management of something entrusted to one’s care. In 1996, John McGowan and Dale Gerding first applied the term antimicrobial stewardship, where they suggested a causal association between antimicrobial agent use and resistance. They also focused on the urgency of large-scale controlled trials of antimicrobial-use regulation employing sophisticated epidemiologic methods, molecular typing, and precise resistance mechanism analysis.[2] Antimicrobial Stewardship(AMS) refers to the optimal selection, dosing, and duration of antimicrobial treatment resulting in the best clinical outcome with minimal side effects to the patients and minimal impact on subsequent resistance.[3]

Stewardship describes the careful and responsible management of something entrusted to one’s care. In 1996, John McGowan and Dale Gerding first applied the term antimicrobial stewardship, where they suggested a causal association between antimicrobial agent use and resistance. They also focused on the urgency of large-scale controlled trials of antimicrobial-use regulation employing sophisticated epidemiologic methods, molecular typing, and precise resistance mechanism analysis.[2] Antimicrobial Stewardship(AMS) refers to the optimal selection, dosing, and duration of antimicrobial treatment resulting in the best clinical outcome with minimal side effects to the patients and minimal impact on subsequent resistance.[3] In simple terms, it refers to a coherent set of actions to promote the responsible use of antimicrobials. AMS is one of the three pillars of an integrated approach to strengthening the health care system. The other two include infection prevention and control(IPC) and patient and medicine safety. The critical components like Antimicrobial Resistance(AMR) surveillance and sufficient supply of quality medicines linked with three pillars help promote equitable and quality health care. The principles of AMS also apply to the use of antimicrobials in the animal and agriculture sectors, emphasizing the wise use of the agents. All healthcare practitioners must embrace roles as frontline stewards to address this emerging health and economic concern of antimicrobial resistance. AMS can be fulfilled by prescribing appropriately and educating the patients and colleagues on the proper use of this increasingly scarce medical resource to protect our current and future patients. With AMS interventions, we aim for sustainable behavior change in an antibiotic prescription.[4] The main intention of this review is to highlight that it is imperative to make the optimal use of antimicrobials available and ensure to have remaining options to treat infectious agents.

The Agency for Healthcare Research and Quality is an excellent resource for antimicrobial stewardship, including best practices in all healthcare settings, methods for developing and improving antimicrobial stewardship, and developing a culture for safety during prescribing. One tool for use by prescribers of antibiotics is their 'Four Moments of Antibiotic Decision Making.'[23] Moment 1 is considering the question if the patient has an infection and does it require antibiotics. Prescribers tend to order antibiotics to the hospitalized patient in response to abnormal clinical signs or lab results (for example- isolated fever or leukocytosis). This moment asks prescribers to pause, rethink and analyze all relevant information to determine the likelihood of any infectious process. At present, COVID 19 pandemic sets as a perfect example of antibiotics prescribed without any bacterial infection. Moment 2 is to think about what cultures should be obtained and the best empiric treatment. This moment focuses on the need for culture data when appropriate before administering the antibiotics. When no specific data is available, there is a tendency for prolonged broad-spectrum antibiotic therapy. The second part of Moment 2 ensures timely administration of empirical therapy based on severity and likely source of infection. For example, patients are at low risk of MRSA for urinary tract infections. Therefore they would not benefit from IV vancomycin. Local antibiotics guidelines should be developed for common inpatient infections- this aids in enacting Moment 2.

Moment 2 is to think about what cultures should be obtained and the best empiric treatment. This moment focuses on the need for culture data when appropriate before administering the antibiotics. When no specific data is available, there is a tendency for prolonged broad-spectrum antibiotic therapy. The second part of Moment 2 ensures timely administration of empirical therapy based on severity and likely source of infection. For example, patients are at low risk of MRSA for urinary tract infections. Therefore they would not benefit from IV vancomycin. Local antibiotics guidelines should be developed for common inpatient infections- this aids in enacting Moment 2. Moment 3 is the question of, after a day or so of antibiotics being used, should the regimen be stopped, narrowed, or changed from IV to oral treatment.  This process should be ongoing.  For instance, most patients with community-acquired pneumonia become stable with normal vital signs by day three and are at an excellent time to switch to oral medications. Antibiotics time-outs should be used to address Moment 3. Nurses and pharmacists are excellent resources to prompt clinicians regarding further plans about antibiotics. At the same time, clinicians should also document their decision regarding the choice of antimicrobial therapy, indication, duration, and dosing. IT department can also help by regularly updating the electronic health records system with prompts to review orders, set up antimicrobial time-outs, etc. This way, clinicians are prompted with indication, duration, dosing, route of therapy. Moment 4 considers how long the antibiotic should be continued for the treatment of the patient's infection. There has been an increasing number of studies that support a shorter duration of therapy than previously prescribed. Local and national antibiotics guidelines help to uniform the duration of antimicrobial therapy prescription. Antimicrobial stewardship is a coordinated effort between interprofessional teams, including clinicians/prescribers, nursing staff, pharmacists, microbiologists, infection prevention teams, and patient safety teams. Targeted goals and multidisciplinary approach interventions result in excellent clinical, economic outcomes.

The success of antimicrobial stewardship programs is deeply connected with the core elements mentioned above as guided by the CDC. The antimicrobial stewardship programs are greatly enhanced by interdepartmental communication and coordination. The significant support from below mentioned groups can play a vital role; Clinicians: All clinicians at any point during patient care have prescribed antibiotics to the patients. Therefore it is crucial that all clinicians fully engage and support antibiotics optimization. Hospitalists and primary care physicians are particularly essential as they comprise a majority of the prescribers. Prescribers can act as good stewards by following the 5 "D"s of antimicrobial stewardship; right Drug, correct Dose, right Drug-route, suitable Duration, timely De-escalation to pathogen-directed therapy. Example actions include making accurate diagnoses, following local antimicrobial guidelines, and timely reviewing the need for therapy.[4] Pharmacy and therapeutics committee: Pharmacists are an integral part of the team. They help in developing and implementing policies that will optimize antibiotic use. For instance, integrating stewardship into order sets[10]. They can also help educate patients regarding medications and be a very useful resource to physicians when prescribing antibiotics. Nurses can especially play an essential role in optimizing diagnostic tests or diagnostic stewardship and patient education. Examples include triaging patients for isolation, a timely collection of culture samples before antimicrobial use, educating patients on how to take antimicrobials at discharge from the hospital.[4] Microbiology lab staff can assist as a part of diagnostic stewardship by guiding proper use of the test. They also help in creating local anti-microbiogram, which help optimize antimicrobial prescriptions. The infection prevention team and epidemiologist assist in tracking, analyzing, and reporting antimicrobial resistance and adverse effect trends. Quality improvement and patient safety teams can advocate for resources dedicated to stewardship interventions. Information technology staff are crucial to incorporating protocols into the stewardship work map. Examples include developing prompts to review antimicrobials and their indication, incorporating order sets in electronic medical records;

Quality improvement and patient safety teams can advocate for resources dedicated to stewardship interventions. Information technology staff are crucial to incorporating protocols into the stewardship work map. Examples include developing prompts to review antimicrobials and their indication, incorporating order sets in electronic medical records; At an individual level, a patient can act as a good antimicrobial steward by using antimicrobials responsibly. Patient participation can be done by taking antimicrobials directed by the prescriber and not storing or using leftover antimicrobials. Likewise, the producer/farmer can also help by not using antimicrobials as growth promoters in the community.

In the United States, around fifteen percent of inpatient patients report penicillin allergy, of which approximately one percent have a severe penicillin allergy.[24] An important step is to not merely accept what is in the electronic medical record (EMR). It is important to reassess the documentation with the patient about the actual event regarding the antibiotic allergic event.  Too often, it is labeled in the EMR as an allergy when it was a side effect of the drug or that the actual allergic effect was not clarified. Some data show that 50% of allergies documented are non-immunologic and mostly adverse effects. Having to substitute another class of drugs rather than beta-lactams can cause a tendency to use broad classes of antimicrobials to be used to treat the patient's infection. The consequences of using inappropriate allergy labels include increase broad-spectrum antibiotics use, limited therapeutic options, increased toxicity, and increased hospital costs. Charneski et al.'s study on 11,872 inpatients revealed that 11.2% of inpatients had allergy labeled with antimicrobial and had increased hospital length of stay, greater antimicrobial use, higher intensive care admission rate, higher readmission rate, and higher mortality.[24][25] Adequate history and physical exam, skin testing, and challenge dosing are few ways to assess the allergy. Nurses can be vital in assessing drug allergies. Pharmacists can also play a pivotal role while updating EMR about patient's medication lists and drug interactions.