The challenge of curbing aminoglycoside resistance: can antimicrobial stewardship programs play a critical role?

ABSTRACT

INTRODUCTION: Aminoglycosides are useful antimicrobials, primarily for serious infections involving aerobic gram-negative pathogens. The inevitable increase in aminoglycoside resistance has led to calls for reducing levels of inappropriate aminoglycoside prescribing through the implementation of various antibiotic stewardship programs (ASPs). These programs mainly include restriction policies and aminoglycoside cycling. Although aminoglycoside resistance rates appear essential for measuring effectiveness of these interventions, most studies have focused on economic outcomes or clinical efficacy and toxicities. Areas covered In the present study we estimated through a systematic literature review, the impact of early cycling studies and ASPs to aminoglycoside resistance rates for gram-negative pathogens. Expert commentary Most ASPs support a positive association between aminoglycoside control policies and decrease of resistance rates. However, factors associated with aminoglycoside resistance are complex and multifactorial making it difficult to attribute resistance changes to a specific intervention. Optimized, high-dose, extended-interval aminoglycoside dosing and subsequent dosage monitoring by means of area under the curve and Cmax estimation, seem the most important strategies to improve clinical outcome, minimize toxicity and diminish resistance. The role of the clinical laboratory, using rapid and advanced assays and involved in pharmacodynamic target achievements, is also crucial to enable individualized or tailored aminoglycoside therapy. Future ASPs will need to combine high-quality epidemiological tools, novel diagnostic approaches and effective infection control measures.