Antimicrobial stewardship program

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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

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
  • 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

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

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.