- Optimizing antimicrobial therapy minimizes antimicrobial resistance and adverse drug reactions.
- In one large cohort study of hospitalized patients, antimicrobials were the second most common cause of adverse events.
- In another study, antimicrobials were the class most frequently associated with prescribing errors.
- Many antimicrobials have been associated with superinfection due to Clostridium difficile, causing morbidity ranging from diarrhea to life threatening colitis.
- A properly framed discussion regarding implementation of a program must present usage and resistance data specific to the hospital, unit, and patient population in addition to the general issues of antimicrobial resistance.
- The main responsibility for an antimicrobial stewardship program rests on physicians and pharmacists.
- Antimicrobial stewardship must operate 24/7 to be effective.
- Educational activities are integral to successful antimicrobial stewardship – both its clinical and administrative aspects.
- A public-access web site is an excellent way to accomplish this.
- Active auditing of prescribing practices is essential for determining the needs and targets of intervention.
- It is highly unlikely that any antimicrobial stewardship effort could be effective in the absence of information technology support.
- An adequate, institution-appropriate budget including personnel compensation is necessary for a successful program.
- Recent payment rules from the Centers for Medicare and Medicaid Services specify that hospitals will no longer be reimbursed for certain nosocomial infections that are perceived to be avoidable. Other third-party payers are likely to follow suit.
- Restriction of selected agents is often difficult to implement:
- entirely unavailable (formulary-based restriction)
- available for only certain indications (criteria-based restriction)
- available only after approval by some authority (preauthorization-based restriction)
General Management and Implementation Issues
Auditing and Feedback
- Real-time auditing helps optimize therapy on an individual-patient basis.
- Constructive and patient-specific feedback from experts in antimicrobial therapy is essential.
- The optimal method of communicating the recommendation to the provider—that is, feedback—must be defined.
- Match the mode of communication to the level of acuity and complexity.
- Passive education about appropriate antimicrobial use can include grand rounds, newsletters, and written guidelines.
- Passive education should be distinguished from active education that occurs in the context of auditing and feedback or preauthorization for specific patients.
- Education about the program itself should not be overlooked.
- A public, up-to-date Web site is an excellent way to inform providers about their institutional antimicrobial stewardship program and offers easy access to information about current strategies:
- Guidelines must be regularly re-evaluated and, if necessary, revised to reflect recent developments reported in the scientific literature.
Application of Information Technology
- Applications on the Web or on personal digital assistants can greatly facilitate rapid updating and dissemination of information compared with paper-based sources.
- Computerized physician order entry further expands the potential for intervening at the time of prescribing.
- Examples of tools are stop-order reminders and/or flags, order sets containing prophylaxis and treatment recommendations, assistance with dosing, information about formulary availability, and approval criteria for restricted antibiotics.
- Many commercially available clinical decision support systems integrate electronic medical records and can facilitate both back-end and front-end approaches to providing real-time, patient-specific recommendations, although they cannot replace clinical judgment.
Specific Antimicrobial Issues
Restriction and/or Preauthorization
- Formulary based restriction: Agents that are entirely unavailable
- Criteria-based restriction: Agents that are available for only certain indications
- Preauthorization-based restriction: Agents that are available only after approval by some authority
- Antimicrobial intravenous-to-oral switch can achieve substantial economic benefits.
- Program staff should consider which drugs to target, criteria for switching, and how the switch is performed.
- Third-party payer criteria for inpatient status may not be affected by intravenous-to-oral switching.
De-escalation or Streamlining
- De-escalation or streamlining is a subclass of auditing and feedback that focuses on changing from initial broad-spectrum (often combination) empiric therapy to a narrower-spectrum (often monotherapy) agent when culture identification and susceptibility results become available.
- Its role in limiting use of broad-spectrum antimicrobials can be fraught with complications.
- Successful strategies must offer clear, predefined criteria for narrowing or discontinuing antimicrobials, while allowing for clinical judgment.
Table 1. Antimicrobial Stewardship Strategies with Associated Barriers and Solutions
|Strategy||Barriers to Effective Implementation||Potential Solutions|
|Auditing and feedback||Problems in identifying patients who are receiving suboptimal therapy||Use rules-based computer systems that combine pharmacy and microbiologic data to flag patients of interest. Manually review antimicrobial order sheets. Review microbiologic data to identify targeted organisms.|
|Difficulty communicating recommendations to providers||Approve policy delineating appropriate means of communicating recommendations.|
|Lack of clarity in appropriate methods for providing feedback||Create nonpermanent forms for written communication in the medical record.|
|Medicolegal concerns about providing feedback in the medical record||Time communication for greatest likelihood of impact (eg, before rounds). Hold intermittent, regularly scheduled antibiotic rounds between the stewardship team and staff from services that heavily use antimicrobials.|
|Restriction and/or preauthorization||Perceived challenge to physician autonomy||Have an approved policy by the medical executive committee. Grant time-restricted approvals (eg, for 24-72 hrs) to balance physicians’ and stewardship concern. Regularly review the use of restricted agents to evaluate their continued restriction.|
|Integration of restriction policies into workflow||Use computerized physician order-entry systems to give restriction notifications automatically. Use dedicated pagers for restricted agents to minimize delays in authorization. Establish clear procedures for authorization after hours.|
|Prescriber education||Lack of knowledge about the role of stewardship programs||Hold antimicrobial stewardship grand rounds to explain the program and provide hospital-specific data.|
|Guideline implementation||Poor knowledge of, and adherence to, guidelines for antimicrobial use||Disseminate information in printed handbooks, integrate it in order sets, and provide easy access on Internet or intranet. Involve opinion leaders from multiple specialties in developing guidelines.|
|Application of information technology||Considerable investment of financial and human resources||Emphasize its importance in patient safety and the potential to avoid substantial costs.|
|Intravenous-to-oral switch||Identification of eligible patients||On a daily basis, review patients receiving intravenous forms of highly bioavailable antimicrobials. Develop criteria to help clinicians determine candidacy for switch (eg, body temperature, white blood cell count).|
|De-escalation or streamlining||Unwillingness of providers to de-escalate or streamline||Refer to studies that demonstrated safety of|
de-escalation or streamlining when resistant organisms were not identified.
|Dosage optimization||Nursing concerns regarding administration and drug incompatibility||Create protocols for administration and list compatible drugs. Consider extended infusion instead of continuous infusion.|