When it comes to stewardship, it’s time to get with the programmers

Reducing antimicrobial use is believed to be a critical intervention in an era of impending catastrophic drug resistance, with little promise in the antimicrobial pipeline (1,2). Up to one-half of human antimicrobial use is believed to be inappropriate in terms of indication, choice of agent or duration (3). After years of research, it is clear that the most important determinant of resistance development is the use of an antimicrobial (4,5). In an effort to counteract overuse, Accreditation Canada now mandates, in its Required Organizational Practices, the existence of a multidisciplinary antimicrobial stewardship program (ASP) at most inpatient health care facilities, including long-term care facilities providing ‘complex continuing care’ (6). Successful ASPs have demonstrated benefits including reduced drug resistance, fewer Clostridium difficile infections and reduced antimicrobial-related toxicity, with no demonstrated adverse clinical outcomes (7,8). Infectious diseases (ID) physicians and microbiologists are natural champions of ASPs with our fund of knowledge and ability to assess ‘appropriateness’ of antimicrobial use. However, most antimicrobial decisions never involve an ID physician. The challenges ASPs face are reaching individual prescribers, the vast majority of whom are primary care providers (9), and changing what are well-entrenched behavioural patterns (10). An ASP is tasked with knowledge translation, defined by the Canadian Institutes of Health Research as “a dynamic and iterative process that includes synthesis, dissemination, exchange and ethicallysound application of knowledge” (11). Locally tailored clinical practice guidelines are created based on drug-resistance patterns and formulary to simplify and standardize antimicrobial decision making – a critical activity for any ASP. This vital information is often closeted on the health region’s intranet or delivered in colleagues’ mailboxes as laminated pocketcards. There may be little in the way of uptake (12) due to many barriers, which include lack of awareness of the available information, poor usability of a guideline (overly technical, too vague or too much information), lack of individualization or, perhaps, attitudinal factors of the prescriber, such as perceived loss of autonomy or skepticism (13). To be successful in overcoming these barriers, we need to engage a variety of skill sets beyond our own, particularly social marketing, human factors and, perhaps most importantly, health information technology (IT) experts. Given the vast amount of dynamic information directed from clinical, microbiological and evidenced-based literature sources, leveraging health IT in the antimicrobial stewardship efforts appears to be an obvious way forward. The use of IT is significantly associated with improvements in clinical practice when considering clinical decision support (14). Well-designed software can be viewed as the medium in which ASP activities and interactions are conducted. Multidisciplinary ASP members, including physician and pharmacist content experts, end-users, social marketers and human factors experts contribute to software design and functionality. IT platforms can execute or facilitate virtually all stewardship activities catalogued by the Infectious Disease Society of America Antimicrobial Stewardship guidelines (7). For example, audit and feedback is greatly enhanced by the use of software, with improved case finding and uptake of recommendations because they are delivered in a timely and actionable manner (15), and the technology facilitates communication between the provider and ASP (16).Automatic messages for highly bioavailable oral agents prescribed by the intravenous route can be generated to remind providers to convert to the enteral route unless there is good reason. The tedious process of obtaining data needed for optimal prescribing, such as recent antimicrobials, microbiology reports, organ function, drug allergies and interactions, can be easily displayed to the user, improving clinical efficiency. The conversion of local clinical practice guidelines into rule-based algorithms can rapidly provide individualized patient management recommendations. The same platform can be used to evaluate the ASP activities by collecting data on antimicrobial use and cost, drug resistance, number of recommendations (versus accepted) and patient outcomes. Ideally, any IT program for ASP implementation is seamlessly integrated, reducing the need for manual entry by obtaining necessary data from the electronic health record (EHR), and computerized order entry ASP recommendations are immediately actionable. Pairing recommendations with the order entry system provides a so-called ‘forcing function’, a strong mediator of behavioural change (17) according to the human factors literature. In the United States (US), with multiple billions invested in incentivized ‘meaningful use’ EHR adoptions (18), there has been a sharp acceleration in the rate of EHR uptake (19). Epic (Wisconsin, USA) and Cerner (Missouri, USA), the EHRs with the largest US market share, particularly for larger organizations, are reported to be increasing their ASP capabilities within the software (16). Third-party vendors have produced ‘add-on’ software to address gaps in the EHR ASP functionality, the most developed of which is probably TheraDoc, evolved from the long established and fruitful ASP at LDS Hospital in Utah (USA) (a branch of Intermountain Health) (16). Such software is typically more elegant and robust for ASP activities compared with the EHR itself, but can represent additional significant cost on top of the core EHR (20). Integrated IT systems for use by the ASP exist in Canada in centres with more established stewardship programs. The Antimicrobial Prescription Surveillance System (APSS) has been developed and validated at the Université de Sherbrooke (Sherbrooke, Quebec), and is fully implemented at the Centre Hospitalier Universitaire de Sherbrooke (CHUS) (Sherbrooke, Quebec) since August 2010. Its broad knowledge base identifies mismatches between guidelines and prescriptions to flag patients who would benefit from pharmacist intervention. At the CHUS, after 20 months of use, it has been associated with a $705,000 reduction in antimicrobial costs and 13% in overall antimicrobial consumption (21). Prescriber acceptance of recommendations, at >90%, has not been limited by paper-based order entry. Adult InfeCtIous dIseAses notes