Antibiotic Awareness Week 2025

Fighting Antimicrobial Resistance Takes All of Us: Strategies to Protect Immunocompromised Patients

As the rate of antimicrobial resistance increases, the importance of everyone doing their part to steward these medications is crucial. Antimicrobial resistance does not discriminate, and it is often the most vulnerable patients that it affects. This includes our immunocompromised patients, like solid organ transplant recipients, hematopoietic cell transplant recipients, and hematologic malignancy patients. As an infectious diseases clinical pharmacist working in an academic medical center with an active cancer center and an exponentially growing transplant institute, I see how difficult but also how critical the need for antimicrobial stewardship in these patients is.

When recommending narrower antibiotic coverage for a solid organ transplant patient with no history of resistance, the response often is “but they are immunocompromised.” In a recent review on this topic¹, it was acknowledged that “the perceived risk of severe illness frequently psychologically outweighs the risk of antibiotic-associated adverse effects.” It is important to recognize that these patients are at high risk of multidrug resistant organisms (infection as well as colonization) and complications and toxicities related to antimicrobials (i.e., C. difficile). It is also important to be able to differentiate when these patients are more similar to immunocompetent patients (e.g., community acquired pneumonia, treatment of asymptomatic bacteriuria) and when they are more different in terms of disease presentation, expected pathogens, and treatment strategies. The more we can protect their antibiotic options by using appropriate antibiotic coverage and durations, hopefully the easier it will be to treat future infections.

As noted, this is a difficult patient population to perform antimicrobial stewardship on but there are several key approaches to optimize. One major strategy is developing close partnership and collaboration between the infectious diseases/antimicrobial stewardship teams and the transplant and oncology teams. The common goal of optimal patient care should be the focus, not competing interests. Teams should work together on multidisciplinary guidelines to discuss areas of debate and promote evidence-based recommendations, preferably before the issue presents itself in a patient case, but also after, if areas for improvement are identified. Constant communication between the teams is paramount to avoid any thoughts that therapy is not being optimized and as a reminder that sometimes less is more. Antimicrobial restrictions should be used as a means to enforce agreed upon guidelines, not to restrict access. It should be noted that the updated 2026 Joint Commission standard for antimicrobial stewardship programs (MM.18.01.01) requires documentation of “the evidence-based use of antibiotics in all departments and services of the hospital.” The use of the word “all” highlights how even regulatory requirements are recognizing the importance of stewardship for all. Collaboration and sharing of information between facilities and health systems that provide care to similar patient populations should also be performed to ensure best practices, identify areas of interest and research (through coalitions and workgroups), and share and compare protocols. We can learn from each other’s experiences to improve care.

Numerous challenges exist in ensuring antimicrobial stewardship in immunocompromised patients but there have been several calls to action^2,3 to emphasize its importance and to increase awareness. We, as a medical community, should individually and collectively all do our part in promoting safe and effective antimicrobial use, which includes antibiotics, antifungals, and antivirals, in all patients.