SHS-UHN ASP Guiding Principles

Complements and Collaborates:  The ASP complements the role of physicians specializing in infectious diseases and clinical pharmacists.  The ASP works in collaboration with IPAC (Infection Prevention and Control) and the Microbiology Laboratory.  Other health care providers, such as nurses and respiratory therapists, can complement the work of the ASP.  The ASP identifies and collaborates with stakeholders across SHS and UHN for interventions and studies it carries out.

Focuses on Effectiveness and Safety:  Antimicrobial stewardship aims to optimize antimicrobial effectiveness while minimizing the potential for development of drug-resistance and adverse effects.  The greatest risk of harm to patients relates to ineffective therapy (i.e. undertreating a severe or potentially severe infection.)  The second greatest risk to patients is related to safety.  Using antimicrobials when they are unnecessary or choosing an antimicrobial regimen that is discordant with a patient’s clinical illness exposes the patient to antimicrobial-resistant organisms and unnecessary drug toxicity.

Cost-Consciousness:  Following the balance of effectiveness and safety, considerations of cost come into play.  Because safe, effective treatment is almost always cost-effective, cost considerations should follow assessment of effectiveness and safety.

Evidence-Informed Approaches to Decision-Making:  Demonstration of effectiveness and safety of antimicrobial therapy usually requires the combination of randomized clinical trials with intention-to-treat analyses (which demonstrate efficacy) and post-marketing surveillance (which demonstrates effectiveness and safety).  Alternatively, quality improvement methodology can demonstrate both effectiveness and safety if appropriate primary endpoints are chosen.

  • Antimicrobial stewardship should not endorse any routine practices that do not satisfy the above principles of effectiveness and safety.  Should there be a current practice that does not satisfy these principles when an alternative practice that does satisfy these principles is available, the alternative practice should be adopted.
  • Should routine practices fail to satisfy these criteria and no alternative be available that satisfies these criteria, then either a quality improvement study (focusing on effectiveness and safety before and after changes are made) or a randomized controlled trial should be considered.  Clinically meaningful end points for effectiveness and safety, antimicrobial utilization, and antimicrobial resistance are measures required for all quality improvement studies or randomized controlled trials.

Considers Local Resistance:  Local antimicrobial resistance data should always be a consideration for making modifications to recommended therapy.  However, the clinical importance of bacterial resistance on clinical outcomes varies among illnesses (e.g. it is always important to use drugs with good activity against pathogens causing infective endocarditis and meningitis, but such a strategy may not be important for cellulitis).

Communicates Results:  The ASP will monitor and disseminate to stakeholders the results of any interventions or studies it carries out.