Stewardship and Empiric Therapy in AMR Gram-Negative Infections

"Stewardship and Empiric Therapy in AMR Gram-Negative Infections " closes the series by reframing stewardship as a tool for getting the right drug to the right patient sooner. Antimicrobial stewardship for novel gram-negative agents is most effective when it expands appropriate empiric use as deliberately as it restricts inappropriate use. Dr. Tamma asks how institutions should steward these drugs, and Dr. Shields explains that his health system restricts them around the clock while using mechanism-based algorithms to guide selection, because most clinicians encounter these organisms too rarely to master the enzymology.

Dr. Shields notes that restriction tends to work smoothly because actionable laboratory data usually emerge during the day. He emphasizes the counterintuitive point that stewardship teams should also be liberal in starting these agents empirically for the right patients, such as those with a recent history of NDM, rather than defaulting to a conventional beta-lactam.

Dr. Pogue builds on this idea, arguing that intensive care unit (ICU) clinicians know their patients best at the moment empiric decisions are made. He describes empowering ICU pharmacists to start novel agents for patients with known histories or high-risk exposures, such as those arriving from a long-term acute care facility, with the option to de-escalate within a day or two. He reminds viewers that the primary goal of stewardship is optimizing outcomes for patients with infections.

In closing reflections, Dr. Shields encourages clinicians who rarely see carbapenem-resistant organisms to engage with the guidance anyway, because it also reexamines long-standing practices for ESBL and AmpC producers and dosing assumptions rooted in weak evidence. Dr. Tamma invites feedback on the guidance and urges clinicians with relevant patient data to publish it. The series ends with a reminder that evidence in this field evolves rapidly and practice should evolve with it.

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