Antibiotic Stewardship Statement for Antibiotic Guidelines – Recommendations of the HICPAC
The Healthcare Infection Control Practices Advisory Committee (HICPAC) is a federal advisory committee chartered to provide advice and guidance to the Centers for Disease Control and Prevention (CDC) and the Secretary of the Department of Health and Human Services (HHS) regarding the practice of infection control and strategies for surveillance, prevention, and control of healthcare-associated infections, antimicrobial resistance and related events in United States healthcare settings. At the November 2015 HICPAC Meeting, CDC asked HICPAC for guidance to help professional organizations incorporate antibiotic stewardship principles into their treatment guidelines. HICPAC formed a workgroup to develop recommendations. The workgroup provided updates and obtained HICPAC input at the March and July 2016 HICPAC Meetings. HICPAC voted to finalize the recommendations at the July 2016 meeting. CDC conducted outreach to partner organizations to ensure awareness of the recommendations. During this outreach, CDC received feedback from professional societies that supplemental implementation guidance and additional details would help them incorporate the principles into their guidelines. At the December 2016 HICPAC meeting, CDC requested additional advice from HICPAC. HICPAC reconvened the workgroup with additional members from key professional societies that develop clinical practice guidelines and recommendations. Additional information about HICPAC is available at the HICPAC website.
Antibiotic resistance and the scarce antibiotic choices for multi-drug resistant organisms are urgent worldwide public health problems. Consequently, antibiotic stewardship has become a critical responsibility for all healthcare institutions and antibiotic prescribers. Professional societies and other organizations developing guidelines for management of infectious diseases that include recommendations for antibiotic prescribing also have an important responsibility in incorporating antibiotic stewardship principles in their recommendations. An antibiotic stewardship program that incorporates the CDC Core Elements (see reference #1) as appropriate for the type of infection and treatment setting should be cited in guidelines as a valued resource for determining the optimal antibiotic selection, dose, route, and duration of treatment. Accordingly, we recommend that guidelines for treatment of infectious diseases include explicit recommendations for antibiotic stewardship relevant to the infections addressed in the guidelines.
- Professional societies and guideline developers should incorporate the principles of diagnostic testing and treatment directly into the recommendations included in their treatment guidelines. Recommendations for diagnostic testing and treatment choices should consider optimal effective treatment, minimal adverse consequences including the development of antibiotic resistance, and healthcare value.
Principles of Testing
- Diagnostic tests should be used wisely to avoid unnecessary antibiotic therapy or therapy that is unnecessarily broad-spectrum, with consideration of healthcare value.
- Rapid diagnostic tests, biomarkers, and decision rules that have acceptable performance characteristics to differentiate bacterial vs. non-bacterial infection should be used to avoid use of unnecessary antibiotic therapy.
- Bacterial cultures with susceptibility testing should be collected, handled and processed promptly and appropriately to identify specific bacteria causing infection and facilitate use of narrow-spectrum antibiotics whenever possible.
- When available and appropriate for the infection and the bacterial isolate, molecular testing to identify specific resistance genes (for example, mec in Staphylococcus, van in Enterococcus) or novel non-culture based phenotypic assays of susceptibility may be used to target antibiotic therapy toward susceptible or resistant isolates.
- Avoid diagnostic testing without an appropriate clinical indication when the results may have unintended consequences. For instance, a urine culture, rapid strep test, or C. difficile testing should not be performed unless the patient meets criteria for testing.
Principles of Treatment
- When appropriate for the infection, source removal (e.g., drainage of abscess, removal of an implicated device) should be accomplished early in the course of treatment.
- Recommendations for initial empiric antibiotic therapy choices should balance treatment efficacy, severity of illness (i.e., sepsis), and the potential for adverse events including the development of antibiotic resistance. When multiple therapeutic options are available, a hierarchy of antibiotic treatment recommendations should be provided with “first choice” options being those with adequate therapeutic efficacy, the lowest risk of facilitating antimicrobial resistance, and the lowest risk of promoting C. difficile and other adverse events, with consideration of healthcare value.
- Recommendations for optimal dosing of antibiotics should be based on efficacy studies and pharmacokinetic and pharmacodynamics principles.
- Recommendations for duration of therapy should be made, emphasizing the shortest effective duration.
- Recommendations for de-escalation of initial empiric antibiotic therapy should be provided, including:
- Using the results of bacterial cultures and diagnostic tests to discontinue or narrow unnecessarily broad-spectrum antibiotic therapy.
- Using other stewardship tools, such as consultation with an antibiotic stewardship team and/or infectious diseases specialist, daily review of antibiotic therapy, and automatic stop orders after adequate treatment duration.
- Potential adverse events related to antibiotic treatment should be noted in the guideline so that providers may opt not to prescribe an antibiotic, or to choose a recommended agent that has a lower potential for adverse events.
- Principles of Testing
- Professional societies and guideline developers should consider presenting advantages and disadvantages of diagnostic tests and antibiotic treatment choices with respect to efficacy and adverse consequences, including antibiotic resistance, with consideration of healthcare value, either in the text or a table.
- Recommendations for patient education regarding diagnostic testing, antibiotic therapy, and duration of therapy should be provided when feasible and appropriate.
To ensure that these principles are incorporated into the recommendations of clinical practice guidelines, organizations and guideline panels review the principles at multiple stages of the guideline development process, including:
- Establishment of the Guideline Panel and Writing Group
- Include the Antibiotic Stewardship Principles in the training and education of the guideline panel or writing group chairs.
- Scoping of the Guideline
- Provide panel chairs with a checklist Cdc-pdf[PDF – 77 KB] of the principles at the scoping phase of the development process so that the principles inform the guideline’s scope.
- Development of PICO(T) Guideline Questions
- Review the principles at each step of the development of PICO(T) questions to determine which of the Principles should be applied.
- Review of Draft Recommendations and Evidence Summaries
- Include a checklist Cdc-pdf[PDF – 77 KB] of the Principles in the instructions for outside reviewers, society boards, and expert panels so that their review of draft recommendations or guidelines will include an assessment of the incorporation of the Principles.
- CDC, “Core Elements of Antibiotic Stewardship Programs Cdc-pdf[PDF – 985 KB],” 2014. [Accessed 22 February 2016].
- Barlam TF, Cosgrove SE, Abbo LM, et al., “Implementing an Antibiotic Stewardship Program: Guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America” Clinical Infectious Diseases; 2016 May 15;62(10):e51-77.
- Dellinger RD. Guidelines for management of severe sepsis and septic shock: 2012 Cdc-pdf[PDF – 3.30 MB]External. Critical Care Medicine 2013;41:580. [Accessed 6 September 2016]
- Dellit, TH, Owens, RC, McGowan, JE, et al,; Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America Guidelines for Developing an Institutional Program to Enhance Antimicrobial Stewardship”; Clinical Infectious Diseases; 2007; 44:159-77
- Morgan DJ, Malani P, Diekema DJ. Diagnostic Stewardship—Leveraging the Laboratory to Improve Antimicrobial Use. JAMA. Published online July 31, 2017.
- National Quality Forum “National Action Plan for Combating Antibiotic Resistant BacteriaExternal” September 2014. [Accessed 22 February 2016]
- Society for Healthcare Epidemiology of America, Infectious Diseases Society of America and Pediatric Infectious Diseases Society ; “Policy Statement on Antimicrobial Stewardship by the Society for Healthcare Epidemiology of America (SHEA), the Infectious Diseases Society of America (IDSA), and the Pediatric Infectious Diseases Society (PIDS)” Infection Control and Hospital Epidemiology; 33(4 – Special Topic Issue: Antimicrobial Stewardship (April 2012): 322-327.
- Society for Hospital Medicine “Fight the ResistanceExternal” 2015. [Accessed 22 February 2016]
- Spellberg B, Srinivasn A, Chambers HF, “New Societal Approaches to Empowering Antibiotic Stewardship”; JAMA. 2016 Feb 25; E1-E2. [Epub ahead of print]
- The Joint Commission; “Antimicrobial Stewardship ToolkitExternal.” [Accessed 22 February 2016]
- Vaughn VM, Chopra V. Revisiting the pancultureExternal. BMJ Quality and Safety. 2016;0:1-4. [epub ahead of print]. [Accessed 6 September 2016]
- The Joint Commission; “New Antimicrobial Stewardship Standard; Standard MM.09.01.01 Cdc-pdf[PDF – 254 KB]External” Issued June 22, 2016. [Last Accessed July 14, 2016]
- The National Institute for Health and Care and Excellence (NICE); “Antimicrobial Stewardship Quality Standard; NICE quality standard [QS121 published April 2016.]” [Accessed August 22,2016]External
Healthcare Infection Control Practices Advisory Committee. Antibiotic Stewardship Statement for Antibiotic Guidelines – The Recommendations of the Healthcare Infection Control Practices Advisory Committee (HICPAC). 2016.
HICPAC Workgroup Members
Jan Patterson, MD, MS (Workgroup Co-Chair), University of Texas Health Science Center at San Antonio; Michael L. Tapper, MD (Workgroup Co-Chair), Lenox Hill Hospital; W. Charles Huskins, MD, MSc, Mayo Clinic College of Medicine (Workgroup Co-Chair); Craig Coopersmith, MD, FACS, FCCM, Society of Critical Care Medicine (SCCM); Stan Deresinski, MD, Infectious Disease Society of America (IDSA); Lynn Janssen, MS, CIC, CPHQ, California Department of Public Health (HICPAC Member); Nalini Singh, MD, MPH, Infectious Disease Society of America (IDSA); Dean Winslow, MD, Infectious Disease Society of America (IDSA); Theoklis Zaoutis, MD, MSCE, American Academy of Pediatrics (AAP).
Daniel J. Diekema, MD, University of Iowa Carver College of Medicine (Co-Chair); Deborah S. Yokoe, MD, MPH, Brigham & Women’s Hospital (Co-Chair); Hilary M. Babcock, MD, MPH, Washington University School of Medicine; Vickie M. Brown, RN, MPH, WakeMed Health & Hospitals; Kristina Bryant, MD, University of Louisville School of Medicine; Sheri Chernetsky Tejedor, MD, Emory University School of Medicine; Vineet Chopra, MBBS, MD, MSc, FACP, FHM, Michigan Medicine and VA Ann Arbor Health System; Susan Huang, MD, MPH; University of California Irvine School of Medicine; Loretta L. Fauerbach, MS, CIC, Fauerbach & Associates, LLC; Michael D. Howell, MD MPH, University of Chicago Medicine; W. Charles Huskins, MD, MSc, Mayo Clinic College of Medicine; Lynn Janssen MS, CIC, CPHQ, California Department of Public Health; Lisa L. Maragakis, MD, MPH, Johns Hopkins University School of Medicine; Jan Patterson, MD, University of Texas Health Science Center San Antonio; Gina Pugliese, RN. MS, Premier healthcare alliance; Selwyn O. Rogers Jr., MD, MPH, FACS, The University of Texas Medical Branch; Tom Talbot, MD, MPH, Vanderbilt University Medical Center; Michael L. Tapper, MD, Lenox Hill Hospital
HICPAC Ex-Officios Members
William B. Baine, MD, Agency for Healthcare Research and Quality (AHRQ); David Henderson, MD, National Institutes of Health (NIH); Melissa Miller, MD, Agency for Healthcare Research and Quality (AHRQ); Paul D. Moore, PhD, Health Resources and Services Administration (HRSA); Elizabeth Claverie-Williams, MS, U.S. Food and Drug Administration (FDA); Melissa A. Miller, BSN, MD, MS, Agency for Healthcare Research and Quality (AHRQ); Gary Roselle, MD, Veterans Administration (VA); Daniel Schwartz, MD, MBA Center for Medicare & Medicaid Services; Jacqueline Taylor, Health Resources and Service Administration (HRSA); Judy Trawick, Health Resources and Service Administration (HRSA)
HICPAC Liaison Representatives
David Banach, MD, MPH, Society for Healthcare Epidemiology of America (SHEA); Darlene Carey, MSN RN CIC NE-BC FAPIC, Association of Professionals of Infection Control and Epidemiology, Inc. (APIC); Vineet Chopra, MBBS, Society of Hospital Medicine; Craig M. Coopersmith, MD, Society of Critical Care Medicine; Elaine Dekker, RN, BSN, CIC, America’s Essential Hospitals; Louise M. Dembry, MD, MS, MBA, Society for Healthcare Epidemiology of America (SHEA); Akin Demehin, American Hospital Association (AHA); Kathleen Dunn, BScN, MN, RN, Public Health Agency of Canada; Sandra Fitzler, RN, American Health Care Association (AHCA); Nancy Foster, American Hospital Association (AHA); Diana Gaviria, MD, MPH, National Association of County and City Health Officials (NACCHO); Jennifer Gutowski, MPH, BSN, RN, CIC, National Association of County and City Health Officials (NACCHO); Valerie Haley, PhD, Association of State and Territorial Health Officials (ASTHO); Holly Harmon, RN, MBA, American Health Care Association (AHCA); Patrick Horine, MHA, DNV Healthcare Inc.; Michael D. Howell, MD, MPH, Society of Critical Care Medicine (SCCM); Marion Kainer, MD, MPH, Council of State and Territorial Epidemiologists (CSTE); Evelyn Knolle, American Hospital Association (AHA); Jacqueline Lawler, MPH, CIC, CPH, National Association of County and City Health Officials (NACCHO); Emily Lutterloh, MD, MPH, Association of State and Territorial Health Officials (ASTHO); Sarah Matthews, MD, National Association of County and City Health Officials (NACCHO); Michael McElroy, MPH, CIC, America’s Essential Hospitals; Lisa McGiffert, Consumers Union; Jennifer Meddings, MD, Society of Hospital Medicine (SHM);Sharon Morgan, MSN, RN, NP-C, American Nurses Association (ANA); Toju Ogunremi, Public Health Agency of Canada; Laurie O’Neil, RN, BN, Public Health Agency of Canada; Michael Anne Preas, RN CIC, Association of Professionals of Infection Control and Epidemiology, Inc. (APIC); Mark E. Rupp, MD, Society for Healthcare Epidemiology of America (SHEA); Mark Russi, MD, MPH, American College of Occupational and Environmental Medicine; Sanjay Saint, MD, MPH, Society of Hospital Medicine (SHM); Robert G. Sawyer, MD, FACS, FIDSA, FCCM, Surgical Infection Society (SIS); Kathryn Spates, the Joint Commission; Linda Spaulding RN, CIC, DNVGL Healthcare; Donna Tiberi, RN, MHA Healthcare Facilities Accreditation Program (HFAP); Margaret VanAmringe, MHS, the Joint Commission; Stephen Weber, MD, Infectious Disease Society of America (IDSA); Elizabeth Wick, MD, American College of Surgeons (ACS); Amber Wood, MSN, RN, CNOR, CIC, FAPIC, Association of periOperative Registered Nurses (AORN)
Arjun Srinivasan, MD, Lauri Hicks, DO, and Erin Stone, MS; the Division of Healthcare Quality Promotion (DHQP), the Centers for Disease Control and Prevention