Antimicrobial stewardship program: Difference between revisions
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==== Outcome Measures ==== |
==== Outcome Measures ==== |
Latest revision as of 06:51, 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
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.