Antimicrobial stewardship in critically ill cancer patients

Patients with cancer including those that need intensive care develop serious infections often and receive multiple courses of antimicrobial therapy for various indications. Heavy antimicrobial usage creates selection pressures leading to the development of resistant microorganisms. Judicious use of antimicrobial agents (antimicrobial stewardship) in this patient population can reduce the development of resistance and prolong the utility of current and novel agents. Other benefits of antimicrobial stewardship include a reduction in the length of stay in the hospital which is associated with reduced health care costs, as well as fewer treatment-related adverse events. Most institutions now have an antimicrobial stewardship team that helps clinical care providers on a daily basis, using well established strategies to ensure appropriate antimicrobial usage. These teams are multidisciplinary and include participants from Infectious Diseases Service, the Pharmacy, the Clinical Microbiology Laboratory, Infection Control, Hospital Epidemiology, and Hospital Administration. Stewardship strategies include formulary restriction and management, preapproval of selected agents, prospective audit of antimicrobial therapy with real time feedback, antibiotic cycling, and/or heterogeneity, among others. Ongoing educational activities are essential for creating awareness initially and for maintaining interest and continued participation institution wide. Measuring the impact of stewardship on specific outcomes (resistance, costs, etc.) is also important and provides valuable feedback regarding the impact of stewardship at individual institutions. Like Infection Control, institutions are now required to have antimicrobial stewardship programs in place.