The Dilemma (or is it dilemna!)
The individual patient v the population: Potentially every patient that walks in the door of the hospital with clinical sepsis could be given the broadest spectrum antimicrobial available on the formulary. This might give the individual the best chance of survival from their sepsis but such management will have the potential to select out Multi Drug Resistant Organisms (MDROs) and cause/store up problems on a population basis.
Antibiotic Stewardship policies are often based on balancing treating the individual patient against minimising MDRO selection in the population.
One could argue that in the making of such policies, general physicians would be most focused on treating the individual patient, clinical microbiologists would be most focused on minimising MDROs in the population, and ID physicians are somewhere in between. A generalisation and an assumption of course but I suspect there may be an element of truth in it. I guess this is why we have stewardship committees with representatives from all these groups.
Communities/cultures may exist where the importance of treating the individual is prioritised; i.e if there is a low threshold for legal action should the patient suffer as a consequence of not receiving the “correct” antimicrobial. This in turn leads to broader spectrum antimicrobial policies and in turn MDRO selection.
And of course there can be micro-cohorts of patients within the hospital setting such as ICU patients. In such cohorts the severity of sickness tips the balance towards treating the patient with the best possible antimicrobial and MDRO minimisation takes a relative back seat. This is why ICUs often become micro-environments within the hospitals for MDROs.
Antimicrobial Stewardship is a (very) complex area and it’s implementation often becomes very political, often because of The Dilemma. The one good thing from my point of view is that it often involves lots of concepts rather than facts. There is a lot out there on the Internet on Antimicrobial Stewardship, most of which is fairly dull reading. To read some more on the varying elements of antimicrobial stewardship click here for a readable and relatively concise article.
Michael
See also Anti-microbial Stewardship in the Hospital Setting: “The Vicious Circles of Resistance”