Antimicrobial stewardship program

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

Further Reading

• How to start an antimicrobial stewardship programme in a hospital. Clin Microbiol Infect. 2019;26(4):447-453. doi: 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: 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: 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.