Consensus guidelines recommend antimicrobial stewardship in all hospitals with the following goals in mind: appropriate and judicious use of antimicrobial agents leading to increased drug safety, reduced antimicrobial utilization, reduction in the development and selection of resistant organisms, cost containment, and improved patient outcomes. Patients with cancer, especially those with hematologic malignancies and neutropenia, develop serious infections often and receive antimicrobial therapy frequently. Consequently, there is considerable opportunity to practice antimicrobial stewardship in this population. Several antimicrobial stewardship strategies such as antimicrobial restriction, cycling, prospective audit and feedback, and de-escalation have been evaluated in patients with cancer. The primary focus has been on the prevention and treatment of bacterial infections in febrile neutropenic patients. These efforts should be expanded to include fungal, viral, and other infections.

The judicious use of antibiotics is an important means to limit the emergence of antibiotic-resistant organisms. Although specific guidelines for neonates are often lacking, antibiotic stewardship principles can be applied to the neonatal intensive care unit. Principles include accurately identifying patients who need antibiotic therapy, using local epidemiology to guide the selection of empiric therapy, avoiding agents with overlapping activity, adjusting antibiotics when culture results become available, monitoring for toxicity, and optimizing the dose, route, and duration of therapy. Neonatal intensive care units should develop interdisciplinary antimicrobial stewardship teams with the support of their institutions. Prescriber audit and feedback, as well as preauthorization and formulary restriction of selected antibiotics, are recommended antimicrobial stewardship interventions. Ancillary strategies include education and computerized decision support. Metrics to evaluate antimicrobial stewardship programs should include measurements of patient safety and quality, such as rates of adverse drug events, and appropriate dosing and timing of perioperative prophylaxis.

Upper respiratory tract infections account for millions of visits to family physicians each year in the United States. Although warranted in some cases, antibiotics are greatly overused. This article outlines the guidelines and indications for appropriate antibiotic use for common upper respiratory infections. Early antibiotic treatment may be indicated in patients with acute otitis media, group A beta-hemolytic streptococcal pharyngitis, epiglottitis, or bronchitis caused by pertussis. Persistent cases of rhinosinusitis may necessitate the use of antibiotics if symptoms persist beyond a period of observation. Antibiotics should not be considered in patients with the common cold or laryngitis. Judicious, evidence-based use of antibiotics will help contain costs and prevent adverse effects and drug resistance.

Clostridium difficile is an intestinal infection associated with antibiotic use, commonly seen in patients with chronic medical issues. The purpose of this review is to discuss the association of C. difficile-associated diarrhea with use of proton pump inhibitors.Multiple medical factors predispose patients to C. difficile-associated diarrhea. Proton pump inhibitors, commonly used for gastric acid suppression, have been shown to have an association with C. difficile-associated diarrhea in both the outpatient and hospital setting. C. difficile-associated diarrhea also has been reported in the pediatric age range linked with proton pump inhibitor use.An association exists between C. difficile infection and proton pump inhibitor use. Treatment options exist for C. difficile-associated diarrhea, although judicious use of proton pump inhibitors and antibiotics, emphasis on hand washing, and appropriate use of patient isolation should be implemented as well.

Pneumonia is a major infectious disease associated with significant morbidity and mortality, with Streptococcus pneumoniae the predominant pathogen in community-acquired cases, accounting for 20% to 50% of bacterial cases. Although pneumococcal resistance to β-lactams is now common worldwide, high-dose parental penicillin G, many other parental β-lactams and some oral β-lactams continue to be efficacious. The new Clinical and Laboratory Standards Institute susceptibility breakpoints for parental penicillin G for nonmeningeal infections (≤2 μg/mL, susceptible; 4 μg/mL, intermediate; ≥8 μg/mL, resistant) introduced in 2008 facilitate appropriate reporting and use of penicillin G. Pneumococcal vaccine usage in children from 2000 has led to significant decreases in morbidity and mortality due to S. pneumoniae in all age groups, and the increase in resistant serotypes, such as 19A, appears to be decreasing following the introduction of an expanded valence vaccine in 2010. Judicious use of antimicrobial agents is the best long-term approach in order to reduce S. pneumoniae resistance.

The use of prophylactic antibiotics against postprocedure infection in patients undergoing transarterial therapy for hepatocellular carcinoma is controversial.To compare the effects of prophylactic antibiotic treatment and no prophylactic antibiotic treatment on infectious complications following transarterial procedures.Clinical trials fulfilling predefined selection criteria were identified by searching several bibliographic databases; a meta-analysis was performed where appropriate.Four trials of inadequate quality consisting of 210 patients were included in the analysis. Only one case of possible postprocedure infection in each group was reported. The rate of patients developing fever (RR 0.91 [95% CI 0.61 to 1.35]), changes in peripheral white blood cell count or serum C-reactive protein levels, and the mean length of hospital stay (mean difference 0.20 [95% CI 0.75 to 1.14]) showed no significant intergroup differences between antibiotic and no antibiotic treatment. Furthermore, the results of the present study indicated that the incidence of bacteremia, septicemia, sepsis or hepatic abscess after transarterial therapy was rare.Antibiotic prophylaxis in patients undergoing transarterial therapy for hepatocellular carcinoma may not be routinely necessary. However, a more judicious use of antibiotics is recommended for patients who are at an increased risk of infection. Nevertheless, prospective trials on a larger scale are clearly needed.

Critically ill patients admitted to the intensive care unit (ICU) are frequently treated with antimicrobials. The appropriate and judicious use of antimicrobial treatment in the ICU setting is a constant clinical challenge for healthcare staff due to the appearance and spread of new multiresistant pathogens and the need to update knowledge of factors involved in the selection of multiresistance and in the patient's clinical response. In order to optimize the efficacy of empirical antibacterial treatments and to reduce the selection of multiresistant pathogens, different strategies have been advocated, including de-escalation therapy and pre-emptive therapy as well as measurement of pharmacokinetic and pharmacodynamic (pK/pD) parameters for proper dosing adjustment. Although the theoretical arguments of all these strategies are very attractive, evidence of their effectiveness is scarce. The identification of the concentration-dependent and time-dependent activity pattern of antimicrobials allow the classification of drugs into three groups, each group with its own pK/pD characteristics, which are the basis for the identification of new forms of administration of antimicrobials to optimize their efficacy (single dose, loading dose, continuous infusion) and to decrease toxicity. The appearance of new multiresistant pathogens, such as imipenem-resistant Pseudomonas aeruginosa and/or Acinetobacter baumannii, carbapenem-resistant Gram-negative bacteria harbouring carbapenemases, and vancomycin-resistant Enterococcus spp., has determined the use of new antibacterials, the reintroduction of other drugs that have been removed in the past due to toxicity or the use of combinations with in vitro synergy. Finally, pharmacoeconomic aspects should be considered for the choice of appropriate antimicrobials in the care of critically ill patients.

The judicious use of antibiotics is an important strategy to preserving efficacy in the treatment of infectious diseases. Infectious disease practitioners are poised to provide patient-specific recommendations for appropriate agents and to optimize dosage and duration of therapy. Antimicrobial stewardship programs (involving pharmacists, physicians and other healthcare providers) are increasing in number as antibiotic resistance increases with a disproportionately small number of new agents being developed. Two strategies for antimicrobial stewardship are currently endorsed by national organizations and include preauthorization/formulary restriction and prospective audit with feedback. As it is important for programs to choose appropriate clinical and financial outcomes goals in order to assure sustainability, we review these strategies and discuss the impact of each on clinical outcomes and costs.

Osteonecrosis of the jaw (ONJ) is defined as exposed bone in the oral cavity that persists despite appropriate therapy. Over the past decade, ONJ has been reported in about 5% of patients with cancer receiving high-dose intravenous bisphosphonates, and more recently in similar patients treated with denosumab, another potent inhibitor of osteoclastic bone resorption. The condition has also been described in patients treated with bisphosphonates for benign diseases, such as osteoporosis, but whether bisphosphonates or denosumab increase the incidence above that seen in untreated patients of comparable age and frailty is yet to be established. The pathogenesis of ONJ is uncertain: the toxic effects of bisphosphonates in a wide variety of cells could increase susceptibility to infections in the oral cavity or impair mucosal healing, and denosumab might interfere with monocyte and macrophage function. Local osteolysis is an important defense against infection on bone surfaces that is blocked by both bisphosphonates and denosumab. Preventive dentistry prior to high-dose antiresorptive therapy is a critical measure in cancer patients, but is not usually justified in patients with osteoporosis. The management of established ONJ lesions is problematic: the greatest success seems to come from vigorous antimicrobial therapy with judicious use of surgical debridement.

Multiple antibiotic resistant Staphylococcus aureus is one of the common causes of severe nosocomial infections, and the gastrointestinal tract is an important source of its transmission. This study assessed the previous usage of antibiotics by healthy adults (university students and villagers) in Amassoma, Nigeria, and investigated the antimicrobial resistance patterns of their intestinal S. aureus isolates. A questionnaire was used for evaluating the previous usage of antibiotics by the volunteers. Stool samples were collected and cultured, and S. aureus isolates were confirmed using standard microbiological protocols. Their antimicrobial resistance patterns were determined using disc-diffusion and agar dilution techniques. In total, 54 (45.0%) volunteers used antibiotics on self-medications, and the practice was significantly higher (p=0.01) among the villagers than among the students. The level of judicious use of prescribed antibiotics was significantly higher (p=0.003) among the students than among the villagers. Thirty-eight (31.7%) healthy adults were colonized with intestinal S. aureus. The percentages of resistance of the isolates to some antibiotics were as follows: ampicillin-68.4%, doxycycline-60.5%, cefoxitin-34.2%, vancomycin-36.8%, erythromycin-34.2%, and gentamicin-5.3%. Twenty-five (65.8%) of the isolates were multidrug-resistant. The need for sound education on the appropriate use of antibiotics and the importance of proper personal hygiene as means of controlling the spread of bacterial antibiotic resistance are highlighted. Thus, effective strategies in these areas are strongly recommended.