The Power of Antimicrobial Stewardship in the Age of Resistance

Antimicrobial stewardship has never been more essential. As antibiotic resistance and superbugs become a global concern, healthcare systems are being pushed to rethink how these life-saving drugs are used. Antimicrobial stewardship programs are working hard to preserve the effectiveness of antimicrobials through careful prescribing, evidence-based practices, and understanding of how these decisions shape patient outcomes.

Co-led by Program Director Tejal Gandhi, MD, and Jerod Nagel, PharmD, BCIDP, the Antimicrobial Stewardship Program at Michigan Medicine has provided essential feedback to clinical teams and significantly reduced inappropriate antibiotic use throughout the healthcare system since its inception a decade ago. Learn more about our current processes for delivering high-quality stewardship, research, and managing global challenges in this age of resistance.

Our Approach to Antimicrobial Stewardship

Our program uses a multifaceted approach which includes a restricted formulary, clinical reviews, interdisciplinary collaboration, and targeted interventions for common conditions that drive antimicrobial use. These efforts help us improve outcomes in both our inpatient and outpatient settings.

Hospital-Based Interventions

A core component of our program is managing a restricted formulary of drugs, many of which are antimicrobials used for multi-drug-resistant bacteria. These are reviewed by our infectious diseases physicians daily to make sure the right antimicrobial is used. 

“We try to use this as an avenue to improve upfront selection and reduce unnecessary use of antibiotics that need to be reserved for more drug-resistant infections,” said Gandhi. 

The program also conducts reviews for patients who have bloodstream infections within the hospital and multidrug-resistant infections at any site. This has led to improvement in the time to appropriate antibiotic therapy, reduced mortality, reduced stays in the ICU, and overall improvement of patient care.

In collaboration with the Allergy and Clinical Immunology Division, we support a beta-lactam allergy evaluation service aimed at de-labeling patients with inaccurate penicillin allergy histories, which can prevent patients (including those with sepsis) from receiving optimal therapy.

“This program has been very beneficial to patients and for antimicrobial stewardship because it allows us to give the best treatment to our patients,” said Gandhi. “Many of these patients are living with a penicillin allergy on their chart but in almost all cases when you test them, they don’t actually have an allergy.” 

This process can reduce adverse events, like Clostridioides difficile infection, caused by using broader-spectrum antibiotic alternatives and has been useful for surgical prophylaxis. When patients can safely receive a beta-lactam, they’re getting a better prophylactic antibiotic prior to surgery and reducing risk of surgical site infection.

We have also focused on common conditions that drive antibiotic use in the hospital, such as community-acquired pneumonia and patients with positive urine cultures. This aims to reduce excess duration of antibiotics and treatment of patients who have asymptomatic bacteriuria (e.g., patients who have a positive urine culture but no UTI—a common misdiagnosis). 

Ambulatory Stewardship and Complex Outpatient Antimicrobial Therapy (COpAT)

We also have an Ambulatory Stewardship Program, led by Lindsay Petty, MD; Nicholas Dillman, PharmD; and Elizabeth Lloyd, MD, to improve antibiotic use in the outpatient setting. We have seen success reducing excess duration of antibiotics for pneumonia, skin and soft tissue infections, and optimizing antibiotic selection for urinary tract infection by providing a multifaceted intervention with education, individual provider feedback, and peer comparison.

In 2024, we launched our COpAT program to improve monitoring for patients discharged on IV antibiotics or complex oral regimens. The program assesses adverse events, makes sure patients are getting lab monitoring and correct follow-up, and medication reconciliation. 

“This helps us answer questions like, did they get the antibiotic after they left the hospital? Do they know how to take it correctly? Are they having side effects?” said Gandhi. “The COpAT program has helped reduce readmissions and emergency room visits by providing an opportunity to use existing data showing oral antibiotics can be used safely for serious infections and to reduce complications when proper monitoring is in place."

Co-led by Shiwei Zhou, MD; Louis Saravolatz, MD; and Xuping Yan, PharmD, the COpAT program addresses a gap in proper monitoring and follow-up, especially for those being discharged to subacute nursing facilities, receiving parenteral antibiotics with dialysis, or discharged home on complex oral antibiotic regimens. At first, the program focused on bone and joint infections such as osteomyelitis, septic arthritis, and diabetic foot infections, due to evidence that appropriately selected oral therapy can be safe and effective in avoiding unnecessary PICC lines and parenteral antibiotics. 

The program has now expanded to include endocarditis and intra-abdominal infections. The long-term goal is to include all patients discharged on complex oral regimens or parenteral IV antibiotics and are not being monitored by our HomeMed group. Early results have been promising, with reduced length of stay and potential impact on readmissions. 

“From the physician experience, we feel like our patients are getting much higher quality of care with this type of oversight, and we’re able to pick up on more adverse events before they become severe,” said Gandhi.

Emerging Trends and Research

Like many health institutions around the world, we have seen a significant rise in antimicrobial resistant organisms. While we are consistently trying to deal with appropriate management of patients with these types of drug-resistant organisms, or superbugs, we have the understanding that we are limited in terms of how many different antimicrobials we can use. All the other work our team does to reduce unnecessary antibiotic use and excessively long courses is with the intention of not only reducing adverse outcomes but preventing the emergence of drug-resistant organisms.

Our research focuses on implementation science, or how the implementation of different interventions affects patient outcomes and processes around prescribing. Some of our researchers have an interest in specific studies around gram-negative resistance, but the bulk of the research has been more on the clinical side, looking at how to make improvements with the interventions we develop.

Overall Impact

Today, antimicrobial stewardship is not just a recommendation; it is a Joint Commission requirement for hospitals. The Infectious Diseases Society of America (IDSA) also recognizes programs through its Centers of Excellence designation, which recognizes hospitals that have the policies and procedures in place to deliver high-quality stewardship with a commitment to improving antimicrobial use and reducing resistance. 

“We are proud to say our program has been designated as an IDSA Antimicrobial Stewardship Center of Excellence,” said Gandhi. “We have many exceptional individuals who are dedicated to the principles of antimicrobial stewardship, and we really try to be a model for other programs.” 

Our program collaborates with the antimicrobial stewardship programs in our health system, U-M Health-Sparrow and U-M Health-West, to share best practices, guidelines, and policies on how to best optimize stewardship throughout the health system.

“Together, we have substantially reduced unnecessary antimicrobial use and improved clinical outcomes, while also developing some cost-saving interventions for our health system,” said Gandhi. “But most importantly, we feel we’ve created interventions that improve the care of our patients and their outcomes, while also trying to mitigate the ongoing emergence of antimicrobial resistance.”

Learn more about the Michigan Medicine’s Antimicrobial Stewardship Program.