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EDITORIALS
Preface
David J. Rosenberg, MD, MPH, FACP, SFHM*
Department of Medicine, Section of Hospital Medicine, Division of General Internal Medicine, North Shore University Hospital, Manhasset, New York.
Antibiotic resistance is a particularly troublesomeproblem in healthcare institutions, and is clearlylinked to antibiotic usage.1–2 The total annual cost ofantimicrobial resistance was estimated to be as highas $35 billion or more in the United States in 1989,3
and much higher in current US dollars. Approximately5 of every 100 patients admitted to a US hospitaldevelops a nosocomial or hospital-associated infection(HAI),4 and many of these infections involve bacteriaresistant to 1 or more antibiotics.5 This is importantbecause hospitalized patients infected with antibiotic-resistant bacteria spend a longer time in the hospital,at increased cost, and are at higher risk of death com-pared to patients with similar infections due to antibi-otic-susceptible bacteria.6 Furthermore, choice of anti-microbial agents across all hospitalized patients isbeing driven by the concern for these resistant organ-isms, potentially contributing to medication costs andhospital length of stay.3
Awareness of the problem of HAIs and their fre-quent association with multidrug-resistant pathogens,led The Joint Commission of the United States toidentify reduction in risk of HAIs as one of theirnational patient safety goals.7 While The Joint Com-mission’s primary focus is on infection control meas-ures (eg, hand hygiene),7 antimicrobial stewardshipcan and should play a key role in reducing the emer-gence and subsequent transmission of antimicrobial-resistant pathogens within the hospital or otherhealthcare settings.
Antimicrobial stewardship has been defined as ‘‘theoptimal selection, dose, and duration of an antimicrobialthat results in the best clinical outcome for the treatmentor prevention of infection, with minimal toxicity to thepatient and minimal impact on subsequent resistance.’’Hospitalists will instinctively find the element of an anti-
microbial stewardship to be inherently valuable to theirclinical practice.8 By instituting and adhering to optimalantimicrobial usage within one’s own practice and acrosstheir institutions, patient care is improved through betterclinical outcomes, reduced microbial resistance, andshorter hospital stays.
This supplement of the Journal of Hospital Medicineexamines key aspects of antimicrobial stewardship in4 interrelated papers with respective focuses on appro-priate initiation and selection of antibiotics (Dr Snyd-man), antimicrobial de-escalation strategies (Dr Kaye),duration and cessation of treatment (Dr File), and thehospitalist’s role in antimicrobial stewardship (DrRosenberg). Three case studies, interwoven through 3of the 4 papers, are used to highlight the applicationof antimicrobial stewardship principles discussed inthe respective papers, in patients commonly encoun-tered in the hospital. The clinical cases deal withhealthcare-associated pneumonia, intra-abdominalinfections (diverticulitis), and central line-associatedbacteremia. The final paper by Rosenberg reviewstrends in antimicrobial resistance, costs of hospital-acquired infections, and lays out the argument forHospitalist participation and, at times, leadership inantimicrobial stewardship programs.
Disclosure: Dr Rosenberg received an honorarium for this work, whichwas jointly sponsored by the American Academy of CME and GLOBEXthrough an unrestricted educational grant from Merck & Co, Inc.
References1. Dellit TH, Owens RC, McGowan JE Jr, et al. Infectious Diseases
Society of America and the Society for Healthcare Epidemiologyof America guidelines for developing an institutional program toenhance antimicrobial stewardship. Clin Infect Dis. 2007;44:159–177.
2. Tacconelli E. Antimicrobial use: risk driver of multidrug resistantmicroorganisms in healthcare settings. Curr Opin Infect Dis. 2009;22:352–358.
3. Phelps CE. Bug/drug resistance: sometimes less is more. Med Care.1989;27:194–203.
4. Weinstein RA. Nosocomial infection update. Emerg Infect Dis. 1998;4:416–420.
5. Hidron AI, Edwards JR, Patel J, et al. NHSN annual update: antimi-crobial-resistant pathogens associated with healthcare-associatedinfections: annual summary of data reported to the National Health-care Safety Network at the Centers for Disease Control and Preven-tion, 2006–2007. Infect Control Hosp Epidemiol. 2008;29:996–1011.
6. Cosgrove SE. The relationship between antimicrobial resistance andpatient outcomes: mortality, length of hospital stay, and health carecosts. Clin Infect Dis. 2006;42(suppl 2):S82–S89.
7. The Joint Commission. Accreditation Program: Hospital. NationalPatient Safety Goals. Effective January 1, 2011. Available at http://www.jointcommission.org/assets/1/6/2011_NPSGs_HAP.pdf.Accessed January 24, 2011.
8. Gerding DN. The search for good antimicrobial stewardship. Jt CommJ Qual Improv. 2001;27:403–404.
*Address for correspondence and reprint requests: David J.Rosenberg, MD, Department of Medicine, Section of Hospital Medicine,Division of General Internal Medicine, North Shore University Hospital,300 Community Dr, Manhasset, NY 11030; Telephone: 516-562-4500;Fax: 516-562-4758; E-mail: [email protected]
Additional Supporting Information may be found in the online version ofthis article.
Received: September 15, Accepted: September 18, 20112012 Society of Hospital Medicine DOI 10.1002/jhm.989Published online in Wiley Online Library (Wileyonlinelibrary.com).
An Official Publication of the Society of Hospital Medicine Journal of Hospital Medicine Vol 7 | No 1 Supplement 1 | January 2012 S1
