Advancing antimicrobial stewardship : Summary of the 2015 CIDSC Report

Background: Antimicrobial resistance (AMR) is recognized as an important global public health concern that has a cross-cutting impact on human health, animal health, food and agriculture and the environment. The Communicable and Infectious Disease Steering Committee (CIDSC) of the Pan-Canadian Public Health Network (PHN) created a Task Group on Antimicrobial Stewardship to look at this issue from a Canadian perspective. Objective: To summarize the key findings of the Task Group Report that identified core components of antimicrobial stewardship programs, best practices, key challenges, gaps and recommendations to advance stewardship across jurisdictions. Methods: Search strategies were developed to identify scientific literature, grey literature and relevant websites on antimicrobial stewardship. The information was reviewed, and based on this evidence, expert opinion and consensus-building, the Task Group identified core components, best practices, key challenges and gaps and developed recommendations to advance stewardship in Canada. Results: The four components of a promising antimicrobial stewardship initiative were: leadership, interventions, monitoring/evaluation and future research. Best practices include a multi-sectoral/multipronged approach involving a wide range of stakeholders at the national, provincial/territorial, local and health care organizational levels. Key challenges and gaps identified were: the success and sustainability of stewardship undertakings require appropriate and sustained resourcing and expertise; there is limited evidence about how to effectively implement treatment guidance; and there is a challenge in ensuring accessibility, standardization and consistency of use among professionals. Recommendations to the CIDSC about how to advance stewardship across jurisdictions included the following: institute a national infrastructure; develop best practices to implement stewardship programs; develop education and promote awareness; establish consistent evidence-based guidance, resources, tools and training; mandate the incorporation of stewardship education; develop audit and feedback tools; establish benchmarks and performance targets for stewardship; and conduct timely evaluation of stewardship programs. Conclusion: Findings of this report will inform a more systematic approach to addressing antimicrobial stewardship Canada-wide. Affiliations 1 Centre for Communicable Diseases and Infection Control, Public Health Agency of Canada, Ottawa, ON 2 Office of the Chief Medical Officer of Health, Edmonton, AB 3 See Acknowledgements section for a full list of Task Group members *Correspondence: jacqueline. arthur@phac-aspc.gc.ca


Introduction
Antimicrobial resistance (AMR) is recognized as an increasingly significant global health issue that threatens the effective prevention, control and treatment of a wide spectrum of infections.In Canada, the emergence of antimicrobial resistant organisms has been identified as a major concern in health care settings and among at-risk populations.Since AMR may emerge in bacteria as a response to selective antimicrobial pressure (i.e., when bacteria is in the presence of an antimicrobial drug), there is a potential risk that fewer and fewer antimicrobials will remain effective in the future.Unnecessary antibiotic treatment has been shown to account for a substantial burden of inappropriate antimicrobial use in Canada (1)(2)(3)(4).Due to growing concern about the link between antimicrobial usage (AMU) and AMR, a shift towards more prudent use of antimicrobials has been one of the areas emphasized in combatting the spread of AMR (5)(6)(7)(8).
Antimicrobial stewardship is the responsible planning and management of resources in order to prevent and moderate the development of AMR.Antimicrobial stewardship initiatives and related programs typically address issues related to AMU in

Methods
The Antimicrobial Use Stewardship Task Group was composed of infectious disease experts, family and other clinical physicians, epidemiologists, microbiologists and public health experts.Search strategies were developed to identify scientific literature, grey literature and relevant websites on antimicrobial stewardship and were supplemented by additional information provided by members.Material was reviewed, and based on this evidence, expert opinion and consensus-building, the Task Group identified core components, best practices, key challenges and gaps and developed recommendations to advance stewardship in Canada.

Results
The search strategies resulted in over 400 articles which were reviewed and summarized for discussion by the Task Group.
For the purposes of the Report, antimicrobial stewardship was defined as "coordinated interventions designed to promote, improve, monitor and evaluate the judicious use of antimicrobials in order to preserve their future effectiveness and promote and protect human health" (9,10).

Core components
Promising stewardship programs suggest that strong interdisciplinary public health action and political engagement can lead to a measurable decrease in AMR and improved optimal AMU in health care settings.While more research is clearly needed to validate this and related findings in community settings, four core components of promising antimicrobial stewardship programs and initiatives emerged: leadership, interventions, monitoring and evaluation and research (Table 1).

Initiatives and best practices
The Task Group identified successful stewardship programs that had been evaluated both within Canada and from other countries.The Canadian initiatives are summarized in Table 2.
After reviewing these programs, the Task Group concluded that strong interdisciplinary public health action and political engagement can lead to a measurable decrease in AMR and improved optimal AMU in health care settings.

Core component Description
Leadership Successful stewardship undertakings are grounded in accountability, appropriate and sustained resources and expertise, adequate support and training and involve specialists in an interdisciplinary manner.

Interventions
Effective stewardship interventions are multipronged and comprehensive.They consist of awareness, education and guidance.Furthermore, they include various tools such as diagnostic tools, providing evidence-based timely information and engaging multiple target groups for maximum effect.

Monitoring and evaluation
To establish the appropriate use of antimicrobials, the literature consistently identifies the critical role of benchmarks, audit and evaluation systems.

Future research
Includes knowledge creation, translation and mobilization.Expertise from across research disciplines must be leveraged in order to address information gaps and ensure that evidence is available and applied for greatest impact.
Table 1: Description of the four core components of antimicrobial stewardship

Key challenges and knowledge gaps
After identifying the core components of effective stewardship and reviewing successful stewardship programs and initiatives, important challenges and knowledge gaps emerged in the Task Group discussion (Table 3).For example, the success and sustainability of stewardship undertakings require appropriate and sustained resourcing and expertise (something which may not always be possible in a given setting or jurisdiction) and gaps exist concerning treatment guidance, its benefits, how to implement it, as well as ensuring accessibility, standardization and consistency of use among professionals.

Recommendations
Based on the core components, best practices, current challenges and gaps, the Task Group developed recommendations to advance antimicrobial stewardship in Canada (Table 4).Implementation of the Report recommendations will need to take into account current developments in the policy and program research domains.
The Task Group also identified two additional considerations.First, that patient safety, avoidance of unwanted side effects and effective infection prevention and control practices are all important factors further contributing to antimicrobial stewardship initiatives.Second, the Task Group suggested that the evaluation of stewardship programs and initiatives be promoted with granting agencies and be considered for inclusion as part of AMU/AMR priorities for funding.

Conclusion
The Task Group identified that leadership, appropriate interventions, monitoring and evaluation, the need for more knowledge about effective stewardship-and the evidence-base that will advance it-are key components of promising antimicrobial stewardship programs and initiatives.There are a number of key challenges and existing knowledge gaps that can be addressed by the Task Group recommendations that have Follow up of effectiveness of treatments/programs: Integration of test-of-cure (re-culturing at the site of infection to determine if infection is still present) into guidance documents.The lack of standardized indicators makes it difficult to determine the effectiveness of the programs/campaigns.

Gaps
Lack of training: Educational and training initiatives regarding stewardship targeted at all prescribing professionals are needed.
Identifying when not to prescribe: More research is required to determine whether producing prescriber guidance on when not to prescribe antibiotics would be beneficial and how to implement it.
Need for rapid diagnosis: Rapid point-of-care diagnostic tools that distinguish bacterial from viral infections and identify and characterize resistant bacteria are needed to guide appropriate use of antimicrobials.Universities, colleges and technical schools that train future prescribers incorporate mandatory stewardship education and continuing education curricula for prescribing professionals.

Monitoring and evaluation
Evidence-based audit and feedback tools be developed to support prescribers and that guidance for prescribers be evaluated, adapted and implemented at regional and local levels Benchmarks be established for optimal antimicrobial use by type of infection and populations at greatest risk for infection and that jurisdictions work together to establish performance targets for stewardship in hospital and other settings; and that timely evaluations of stewardship programs be conducted and publicly accessible.

Future research
Further evidence about prescribing behaviours of professionals be collected, shared and mobilized so that specific interventions for these professions can be implemented.
Changes be made to health care practitioners' practice regulations and that further evidence will need to be gathered to guide and support such changes.Better managing antimicrobial use is a shared responsibility among multiple stakeholders including public health and health care professionals, health care organizations, local, provincial, territorial, national governments, the research community and others who provide and use antimicrobials and who care for the people who use them.The development, promotion and implementation of initiatives to promote optimal use of antimicrobials across Canada will require collaboration among all of these stakeholders, helping to create synergies that will effectively combat AMR.

Table 2 :
Examples of best practices for antimicrobial stewardship in Canada 1 (9) objective of this article is to summarize the CIDSC Task Group Report on Antimicrobial Use Stewardship(9), which identifies the core components of antimicrobial stewardship programs and best practices in human health settings in Canada, highlights the challenges and gaps and presents a series of recommendations to advance antimicrobial stewardship in Canada.

Table 3 :
Current challenges and gaps in antimicrobial stewardship

Table 4 :
Recommendations to CIDSC for core components of antimicrobial stewardship practices in Canada

1
(9)se are highlights of only some of the programs in Canada.For a more complete list of initiatives in both Canada and abroad, refer to the full Report(9)

Table 2 continued
been put forward.These are currently under consideration by governments and health care experts.