Direct Measurement of Performance: A New Era in Antimicrobial Stewardship

Area of Science:

• Healthcare Quality Improvement
• Infectious Disease Management
• Health Informatics

Background:

• Current antimicrobial stewardship program (ASP) performance metrics, such as infection rates (e.g., *Clostridioides difficile*), are indirect and susceptible to external confounding factors.
• These indirect metrics do not solely reflect the effectiveness of ASPs, as they can be influenced by diagnostic methods, algorithms, and patient transmission dynamics.

Purpose of the Study:

• To critically appraise existing metrics used for evaluating antimicrobial stewardship programs (ASPs).
• To advocate for the adoption of antimicrobial use as the primary performance measure for ASPs.
• To propose novel methods for adjusting antimicrobial use data for quality of care and institutional microbiological burden to enable robust comparisons.

Main Methods:

• This study is a narrative review critically appraising existing stewardship metrics.
• It examines the evolution of healthcare informatics and electronic medical records in enabling antimicrobial use measurement.
• Novel formulas are proposed to adjust antimicrobial use data for inter-facility comparisons.

Main Results:

• Antimicrobial use is a direct and controllable metric for ASP performance, unlike indirect infection rates.
• Electronic health records and informatics advancements facilitate accurate measurement of antimicrobial consumption.
• Existing metrics are often confounded by factors outside an ASP's direct control.

Conclusions:

• Antimicrobial stewardship programs (ASPs) should be primarily evaluated based on their direct impact on antimicrobial use.
• Adopting antimicrobial use as the main performance indicator allows for a clearer separation of ASP effectiveness from other institutional factors.
• Adjusted antimicrobial use metrics can facilitate meaningful comparisons across different healthcare networks and facilities.