The five ‘Ds’ of antimicrobial stewardship
Antimicrobial overuse and misuse are the main drivers of antimicrobial resistance, a global threat to public health. As part of the team developing infectious diseases content for UpToDate® Lexidrug™ referential drug solution (formerly Lexicomp®), we have incorporated key antimicrobial stewardship-related content into our anti-infective monographs to support clinicians in strengthening antimicrobial stewardship.
This guidance is based on the five Ds of antimicrobial stewardship:
- Diagnosis
- Drug
- Dose
- De-escalation
- Duration
Diagnosis: Avoiding overuse and misuse of antimicrobials
We start with diagnosis as a reminder to carefully evaluate the patient’s condition before committing to treatment options: Does the condition really require antimicrobial therapy?
For example, antibacterials are often unnecessarily prescribed for upper respiratory infections. Therefore, the guidance provided for rhinosinusitis dosing within the Lexidrug monograph includes a note directly sourced from guideline recommendations stating that initial observation and symptom management is adequate in most cases. It also provides further details on when antibacterial therapy may be appropriate and what effective dosing may be in those various scenarios. This helps to emphasize that, for the majority of cases, antibacterials are not first-line therapy and may give providers confidence to hold off, thereby reducing the development of antimicrobial resistance.
Drug and dose: Supporting clinicians in effective decision-making
When antibacterial therapy is appropriate for patients, getting the drug and dose correct is essential to safely treat the condition and avoid any potential adverse events.
Ensuring the appropriate drug is chosen is very important. Consider a patient with a Salmonella GI infection, for whom we might want to prescribe ciprofloxacin for typhoid fever. Before proceeding, a check of references and guidelines would let us know that it is important to verify the MIC (minimum inhibitory concentration) before using this drug as there is increasing resistance to fluoroquinolones among Salmonella species.
Returning to evidence and guidelines also helps ensure that the dose is appropriate for a given infection. Consider the previous rhinosinusitis example: If antibacterial therapy is deemed appropriate, and amoxicillin and clavulanate is chosen by the provider, it is important to assess patient-specific risk factors when deciding on a dose. Guidelines recommend high-dose amoxicillin and clavulanate for patients at risk for poor outcomes or pneumococcal resistance.
De-escalation and discontinuation: Finding next steps for treatment
Assessing opportunities to de-escalate therapy by switching to an agent with a narrower spectrum of activity or to discontinue agents that are no longer necessary to manage an infection (empiric to directed therapy) is another important step in the antimicrobial stewardship process. Ask: Can the antimicrobial be switched to an agent with more narrow coverage or from an IV agent to an oral one?
For example, in Lexidrug monographs that include an indication for adjunctive empiric gram-negative coverage in sepsis/septic shock, we provide information on when it would be appropriate to narrow that coverage. For parenteral antibacterial agents with an indication for treatment of intra-abdominal infection, we provide direction on when to consider switching to an oral antibacterial agent.
Duration: Optimizing antimicrobial use
Shortening the duration of therapy is another way to reduce unnecessary antimicrobial therapy and may lead to reduced drug-related adverse events and shorter hospital stays. It may even decrease development of antimicrobial resistance and superinfections.
For instance, in Lexidrug monographs for antibacterial agents that are used for the treatment of gram-negative bloodstream infection, detailed duration information will alert clinicians to situations where it is appropriate to use a shortened duration.
The importance of pharmacokinetic and pharmacodynamic enhancements
Anti-infective information is valuable to a variety of clinicians and should be a tool used beyond just those practicing in the specialty of infectious disease. That’s why we added anti-infective considerations in our Lexidrug pharmacokinetic monograph field, including addition of the following:
- Parameters associated with efficacy (e.g., time above the MIC, AUC to MIC goals)
- Expected serum concentrations
- Parameters associated with toxicity
- Post-antibiotic effect
All of this information is meant to provide healthcare professionals, whether they specialize in infectious diseases or not, the support they need to fight against the spread of antimicrobial resistance while still treating patients safely and effectively.
Learn more about infectious diseases and other Lexidrug content sets and tools.
