Antimicrobial resistance remains one of the most critical challenges in modern medicine. According to the World Health Organization (WHO), the spread of resistant microorganisms significantly limits the efficacy of infectious disease treatments, driving up both mortality rates and healthcare expenditures. Of particular concern is the irrational use of broad-spectrum antibiotics—including carbapenems, third- and fourth-generation cephalosporins, and fluoroquinolones—which serves as a primary driver of resistance development.
In Georgia, antimicrobial resistance rates against many clinically significant pathogens remain high. Acinetobacter spp., Klebsiella pneumoniae, and Pseudomonas aeruginosa are of particular concern, frequently presenting as multidrug-resistant (MDR) strains. Recent national data indicate that resistance to carbapenems, third-generation cephalosporins, and fluoroquinolones remains a substantial challenge, further underscoring the urgent need to implement antimicrobial stewardship (AMS) programs.
The primary objective of developing and implementing this program is to ensure the selection of the right antibiotic, at the right dose, for the right duration, and for the right patient. This approach not only improves clinical outcomes but also mitigates the risk of resistance development and ensures the rational use of reserve antibiotics.
Based on an analysis of antibiotic consumption and microbiological data conducted in 2024 at the Academician G. Chapidze Emergency Cardiology Center, a decision was made to update the existing antimicrobial stewardship program. To this end, a multidisciplinary working group was established, bringing together intensivists, physicians, an infectious disease specialist, an epidemiologist, a quality manager, and clinical administration representatives.
During the program update process, the principles governing empirical and reserve antibiotic utilization were revised, organ-system-structured guidelines were developed, and mandatory pre-authorization from an infectious disease specialist was instituted for prescribing reserve group antibiotics. Special emphasis was placed on the importance of microbiological testing; consequently, collecting and culturing biological samples prior to initiating antibiotic therapy in patients with signs of infection became a core program requirement.
The final version of the program was approved in 2024, while staff training and the practical implementation process were finalized in January 2025. Concurrently, an electronic antibiotic monitoring system was deployed, enabling regular evaluation of antimicrobial consumption, its structure, and its dynamics.
Antibiotic consumption was evaluated using the World Health Organization’s AWaRe classification and the Defined Daily Dose (DDD) methodology. The analysis was conducted based on consumption metrics calculated per 1,000 patient-days, which is one of the most widely accepted methods for benchmarking antimicrobial use in international practice.
Among the most frequently isolated pathogens from microbiological cultures at the Center were Escherichia coli, Pseudomonas aeruginosa, Klebsiella pneumoniae, Staphylococcus aureus, and Enterococcus spp. These data confirm that a significant proportion of infectious complications in the cardiac inpatient care setting is associated with the circulation of multidrug-resistant microorganisms.
Following the implementation of the antimicrobial stewardship program, a downward trend in the consumption of broad-spectrum antibiotics was observed across almost all major classes. The reduction in carbapenem use was particularly significant, with average consumption decreasing from 191.75 DDD/1,000 patient-days to 79.25 DDD/1,000 patient-days, representing a statistically significant difference. The utilization of third- and fourth-generation cephalosporins also declined substantially.
Notably, no significant changes were observed in the consumption of fluoroquinolones and macrolides, whereas a downward trend was recorded in the aminoglycoside and polymyxin groups. These results indicate that the intervention had the greatest impact precisely on those antibiotics that pose the highest risk in terms of promoting resistance.
One of the landmark achievements of the stewardship program is the enhanced control over the prescription process for Watch and Reserve group antibiotics. Consequently, the role of microbiological testing in clinical decision-making was strengthened, leading to more tailored and individualized antibiotic therapy.
Despite the progress achieved, completely restricting the use of reserve antibiotics is currently unfeasible given the high baseline resistance rates nationwide. This is particularly true for intensive care, internal medicine, and cardiology patients, who are often admitted to the Center after prolonged hospitalizations at other medical facilities and present with a high risk of severe infectious complications.
Moving forward, critical priorities include the continuous monitoring of antibiotic consumption, the introduction of screening for multidrug-resistant microorganism colonization, the improvement of early isolation measures, and the integrated analysis of antibiotic consumption data alongside cumulative antibiograms.
The experience of the Chapidze Emergency Cardiology Center demonstrates that a well-organized, multidisciplinary antimicrobial stewardship program can effectively reduce the utilization of broad-spectrum antibiotics in real-world clinical practice. Such programs not only contribute to resistance control but also enhance patient safety, treatment quality, and the rational utilization of healthcare resources.
Author: Otar Chokoshvili, MD, PhD, Epidemiologist
