Antimicrobial stewardship program: Difference between revisions
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=== Hospital Leadership Commitment === |
=== Hospital Leadership Commitment === |
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* Need support from senior leadership, including chief medical officer, chief nursing officer, and director of pharmacy |
* Need support from senior leadership, including chief medical officer, chief nursing officer, and director of pharmacy |
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+ | |||
* Need leaders to give time to manage the program, resource (including staffing) |
* Need leaders to give time to manage the program, resource (including staffing) |
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+ | * Leaders should champion the program |
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⚫ | |||
+ | * Regular reporting to senior leadership |
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− | * Available expertise on infection management |
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+ | |||
⚫ | |||
⚫ | |||
− | * Other actions aiming at responsible antimicrobial use |
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+ | * The leaders must be accountable for management and outcomes |
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− | * Monitoring and surveillance |
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+ | * Co-leaders should have clear delineation of responsibilities and expectations |
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⚫ | |||
+ | |||
+ | === Pharmacy Expertise === |
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+ | * Available expertise on infection management from ID-trained pharmacists or, if none exists, general clinical pharmacists |
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+ | |||
+ | === Action === |
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+ | * Choose interventions that will best improve outcomes |
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+ | * The most effective evidence-based interventions are: |
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+ | ** Prospective audit and feedback, which can be made more effective with face-to-face meetings with prescribers ("handshake stewardship") |
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⚫ | |||
+ | * Other interventions include: |
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+ | ** Facility-specific treatment guidelines, particularly for CAP, UTI, and SSTI, but possibly also for [[sepsis]], [[Staphylococcus aureus]] infection, [[Clostridioides difficile]] infection, and [[OPAT]] |
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+ | ** Antibiotic timeouts, with scheduled reassessment at 48-72 hours by the prescriber |
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+ | *** Not a substitution for prospective audit and feedback |
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+ | *** May not decrease antimicrobial use, but may improve appropriateness |
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+ | ** Assessing penicillin allergy |
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+ | *** History, challenge doses, and skin testing |
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+ | *** May involve nurses for the assessments |
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+ | * Pharmacy-based interventions include: |
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+ | ** Documentation of indication for antibiotics can improve antibiotic use |
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+ | ** Automatic substitutions from IV to oral therapy |
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⚫ | |||
+ | ** Dose adjustments and optimization |
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⚫ | |||
⚫ | |||
+ | ** Duplicative therapy alerts |
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+ | ** Time-sensitive automatic stop orders |
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+ | ** Detection and prevention of [[drug-drug interactions]] |
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⚫ | |||
+ | * Microbiology- and laboratory-based interventions include: |
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+ | ** Selective reporting of susceptibility testing |
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+ | ** Comments in microbiology reports |
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⚫ | |||
⚫ | |||
⚫ | |||
⚫ | |||
+ | * Nursing-based interventions include: |
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+ | ** Optimizing microbiology culture collection |
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+ | ** IV to oral transitions |
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+ | ** Prompting antibiotic timeouts |
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+ | |||
+ | === Tracking === |
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+ | |||
+ | ==== Antimicrobial Use ==== |
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+ | |||
+ | * Days of therapy (DOTs) or defined daily doses (DDDs) |
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+ | * Stadardized antimicrobial administration ratio (SAAR), which compares actual use to expected use based on a statistical model |
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+ | |||
+ | ==== Outcome Measures ==== |
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+ | |||
+ | * [[Clostridioides difficile]] infection rates |
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+ | * [[Antimicrobial resistance]] |
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+ | * Financial impact, though costs often stabilize after initial improvement |
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+ | |||
+ | ==== Process Measures for QI ==== |
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+ | * For prospective audit and feedback, tracking the types of recommendations and whether they are accepted |
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⚫ | |||
+ | * 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: |
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+ | ** 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 |
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+ | ** Monitoring the frequency of duplicative therapy (e.g. double anaerobic coverage) |
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+ | ** Assessing the appropriateness of discharge antibiotics and durations |
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⚫ | |||
⚫ | |||
+ | * Regular updates to prescribers, pharmacists, nurses, and leadership on both outcome and process measures |
||
− | * Prospective audit and feedback |
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+ | * Provider-specific reports with comparisons to peers can be helpful |
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− | * Didactic educational activities, including lectures and pamphlets |
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− | * Facility-specific clinical practice guidelines for common syndromes |
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⚫ | |||
− | * Prescriber-led review, including antibiotics time-outs and stop orders |
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− | * Computerized clinical decision-making support at the time of prescribing |
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⚫ | |||
⚫ | |||
− | * Interventions to increase the use of oral antibiotics for initial therapy as well as timely transition from IV to oral antibiotics |
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⚫ | |||
− | * Allergy assessments and penicillin skin testing for patients with reported [[β-lactam allergy]] |
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⚫ | |||
− | * Selective and cascade reporting of antimicrobial susceptibility |
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⚫ | |||
⚫ | |||
⚫ | |||
− | === |
+ | === Education === |
⚫ | |||
+ | * May include didactic presentations, posters, flyers, and newsletters, and mailing list emails |
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⚫ | |||
* Cycling antibiotics |
* Cycling antibiotics |
||
Revision as of 14:33, 10 August 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
- The most effective evidence-based interventions are:
- Prospective audit and feedback, which can be made more effective with face-to-face meetings with prescribers ("handshake stewardship")
- Preauthorization
- Other interventions include:
- Facility-specific treatment guidelines, particularly for CAP, UTI, and SSTI, but possibly also for sepsis, Staphylococcus aureus infection, Clostridioides difficile infection, and OPAT
- 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 include:
- 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 include:
- 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 include:
- Optimizing microbiology culture collection
- IV to oral transitions
- Prompting antibiotic timeouts
Tracking
Antimicrobial Use
- Days of therapy (DOTs) or defined daily doses (DDDs)
- Stadardized 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