Antimicrobial stewardship program: Difference between revisions

Latest revision as of 10:51, 21 September 2022

Background

Program to ensure that antimicrobials are used appropriately, in order to improve patient outcomes

Core Elements

Hospital Leadership Commitment

Need support from senior leadership, including chief medical officer, chief nursing officer, and director of pharmacy

Need leaders to give time to manage the program, resource (including staffing)
Leaders should champion the program
Regular reporting to senior leadership

Accountability

The leaders must be accountable for management and outcomes
Co-leaders should have clear delineation of responsibilities and expectations

Pharmacy Expertise

Available expertise on infection management from ID-trained pharmacists or, if none exists, general clinical pharmacists

Action

Choose interventions that will best improve outcomes

Priority Interventions

Prospective audit and feedback, which can be made more effective with face-to-face meetings with prescribers ("handshake stewardship")
Preauthorization

Infection-Based Interventions

Facility-specific treatment guidelines, particularly for CAP, UTI, and SSTI, as well as sepsis, Staphylococcus aureus infection, Clostridioides difficile infection
Review of the management of cases of sepsis, Staphylococcus aureus infection, Clostridioides difficile infection
Review of culture-proven invasive infections
Review of planned OPAT

Provider-Based Interventions

Antibiotic timeouts, with scheduled reassessment at 48-72 hours by the prescriber
- Not a substitution for prospective audit and feedback
- May not decrease antimicrobial use, but may improve appropriateness
Assessing penicillin allergy
- History, challenge doses, and skin testing
- May involve nurses for the assessments

Pharmacy-Based Interventions

Documentation of indication for antibiotics can improve antibiotic use
Automatic substitutions from IV to oral therapy
Interventions to reduce the duration of antibiotics to shortest effective duration
Dose adjustments and optimization
- PK monitoring and adjustment of aminoglycosides and vancomycin
- Alternative dosing of β-lactams
Duplicative therapy alerts
Time-sensitive automatic stop orders
Detection and prevention of drug-drug interactions
Reducing use of antibiotics with increased risk of Clostridioides difficile infection

Microbiology- and Laboratory-Based Interventions

Selective reporting of susceptibility testing
Comments in microbiology reports
Development of stratified antibiograms (e.g. by location or age)
Rapid viral testing for respiratory pathogens to reduce the use of inappropriate antibiotics
Rapid diagnostic testing on blood specimens
Serial procalcitonin in ICU patients

Nursing-Based Interventions

Optimizing microbiology culture collection (see also Diagnostic stewardship of urine cultures)
IV to oral transitions
Prompting antibiotic timeouts

Tracking

Antimicrobial Use

Days of therapy (DOTs) or defined daily doses (DDDs)
Standardized antimicrobial administration ratio (SAAR), which compares actual use to expected use based on a statistical model

Outcome Measures

Clostridioides difficile infection rates
Antimicrobial resistance
Financial impact, though costs often stabilize after initial improvement

Process Measures for QI

For prospective audit and feedback, tracking the types of recommendations and whether they are accepted
For preauthorization, tracking agents that are generating requests and ensuring that preauthorization is not delaying appropriate therapy
For facility-specific treatment guidelines, monitoring adherence
Others can include:
- Monitoring how often antibiotic timeouts are done and if changes are made
- Evaluating medication use for select antibiotics, typically using standardized audit forms
- Monitoring conversions from IV to oral antimicrobials
- Monitoring the frequency of duplicative therapy (e.g. double anaerobic coverage)
- Assessing the appropriateness of discharge antibiotics and durations

Reporting

Regular updates to prescribers, pharmacists, nurses, and leadership on both outcome and process measures
Provider-specific reports with comparisons to peers can be helpful

Education

Education and practical training is helpful but not enough
May include didactic presentations, posters, flyers, and newsletters, and mailing list emails

Ineffective Interventions

Cycling antibiotics

@@ Line 5: / Line 5: @@
 == Core Elements ==
+=== Hospital Leadership Commitment ===
-* Senior hospital management leadership towards antimicrobial stewardship
+* Need support from senior leadership, including chief medical officer, chief nursing officer, and director of pharmacy
-* Accountability and responsibilities
-* Available expertise on infection management
+* Need leaders to give time to manage the program, resource (including staffing)
-* Education and practical training
+* Leaders should champion the program
-* Other actions aiming at responsible antimicrobial use
+* Regular reporting to senior leadership
-* Monitoring and surveillance
-* Reporting and feedback
+=== Accountability ===
+* The leaders must be accountable for management and outcomes
+* Co-leaders should have clear delineation of responsibilities and expectations
+=== Pharmacy Expertise ===
+* Available expertise on infection management from ID-trained pharmacists or, if none exists, general clinical pharmacists
+=== Action ===
+* Choose interventions that will best improve outcomes
+==== Priority Interventions ====
+* Prospective audit and feedback, which can be made more effective with face-to-face meetings with prescribers ("handshake stewardship")
+* Preauthorization
+==== Infection-Based Interventions ====
+* Facility-specific treatment guidelines, particularly for CAP, UTI, and SSTI, as well as [[sepsis]], [[Staphylococcus aureus]] infection, [[Clostridioides difficile]] infection
+* Review of the management of cases of [[sepsis]], [[Staphylococcus aureus]] infection, [[Clostridioides difficile]] infection
+* Review of culture-proven invasive infections
+* Review of planned OPAT
+==== Provider-Based Interventions ====
+* Antibiotic timeouts, with scheduled reassessment at 48-72 hours by the prescriber
+** Not a substitution for prospective audit and feedback
+** May not decrease antimicrobial use, but may improve appropriateness
+* Assessing penicillin allergy
+** History, challenge doses, and skin testing
+** May involve nurses for the assessments
+==== Pharmacy-Based Interventions ====
+* Documentation of indication for antibiotics can improve antibiotic use
+* Automatic substitutions from IV to oral therapy
+* Interventions to reduce the duration of antibiotics to shortest effective duration
+* Dose adjustments and optimization
+** PK monitoring and adjustment of [[aminoglycosides]] and [[vancomycin]]
+** Alternative dosing of β-lactams
+* Duplicative therapy alerts
+* Time-sensitive automatic stop orders
+* Detection and prevention of [[drug-drug interactions]]
+* Reducing use of antibiotics with increased risk of [[Clostridioides difficile]] infection
+==== Microbiology- and Laboratory-Based Interventions ====
+* Selective reporting of susceptibility testing
+* Comments in microbiology reports
+* Development of stratified antibiograms (e.g. by location or age)
+* Rapid viral testing for respiratory pathogens to reduce the use of inappropriate antibiotics
+* Rapid diagnostic testing on blood specimens
+* Serial procalcitonin in ICU patients
+==== Nursing-Based Interventions ====
+* Optimizing microbiology culture collection (see also [[Diagnostic stewardship of urine cultures]])
+* IV to oral transitions
+* Prompting antibiotic timeouts
+=== Tracking ===
+==== Antimicrobial Use ====
+* Days of therapy (DOTs) or defined daily doses (DDDs)
+* Standardized antimicrobial administration ratio (SAAR), which compares actual use to expected use based on a statistical model
+==== Outcome Measures ====
+* [[Clostridioides difficile]] infection rates
+* [[Antimicrobial resistance]]
+* Financial impact, though costs often stabilize after initial improvement
+==== Process Measures for QI ====
+* For prospective audit and feedback, tracking the types of recommendations and whether they are accepted
+* For preauthorization, tracking agents that are generating requests and ensuring that preauthorization is not delaying appropriate therapy
+* For facility-specific treatment guidelines, monitoring adherence
+* Others can include:
+** Monitoring how often antibiotic timeouts are done and if changes are made
+** Evaluating medication use for select antibiotics, typically using standardized audit forms
+** Monitoring conversions from IV to oral antimicrobials
+** Monitoring the frequency of duplicative therapy (e.g. double anaerobic coverage)
+** Assessing the appropriateness of discharge antibiotics and durations
+=== Reporting ===
+* Regular updates to prescribers, pharmacists, nurses, and leadership on both outcome and process measures
+* Provider-specific reports with comparisons to peers can be helpful
+=== Education ===
+* Education and practical training is helpful but not enough
+* May include didactic presentations, posters, flyers, and newsletters, and mailing list emails
+== Ineffective Interventions ==
+* Cycling antibiotics
+== Further Reading ==
+* How to start an antimicrobial stewardship programme in a hospital. ''Clin Microbiol Infect''. 2019;26(4):447-453. doi: [https://doi.org/10.1016/j.cmi.2019.08.007 10.1016/j.cmi.2019.08.007]
+* Implementing an Antibiotic Stewardship Program: Guidelines by the IDSA and the SHEA. ''Clin Infect Dis''. 2016;62(10):e51-e77. doi: [https://doi.org/10.1093/cid/ciw118 10.1093/cid/ciw118]
+* IDSA and the SHEA Guidelines for Developing an Institutional Program to Enhance Antimicrobial Stewardship. ''Clin Infect Dis''. 2007;44:159-77. doi: [https://doi.org/10.1086/510393 10.1086/510393]
+* ''The Core Elements of Hospital Antibiotic Stewardship Programs: 2019''. Atlanta, GA: US Department of Health and Human Services, CDC; 2019. Available at https://www.cdc.gov/antibiotic-use/core-elements/hospital.html.