Antimicrobial Stewardship - Gross

PDAT 506 Exam 3

What is antimicrobial stewardship?

A systematic process to optimize antimicrobial use to improve patient outcomes while minimizing unintended consequences

How does antimicrobial stewardship optimize antimicrobial use?

• Optimizing antimicrobial use:

  • Abx are utilized only when indicated

  • Using the ideal agent for the indication

  • Dose, route, duration

  • Providing the drug safely

How does antimicrobial stewardship minimize unintended consequences?

Minimizes:

• Resistance

• Toxicity/adverse effects including C. difficile-associated diarrhea

What are the 5 D’s of patient level stewardship?

• Diagnosis

  • Do we agree with the diagnosis? What data supports this diagnosis?

• Drug

  • What is the most effective drug?

• Dose

  • Is the medication dosed correctly?

• De-escalation

  • Can we deescalate therapy?

• Duration

  • How long are we treating for?

What is the empiric therapy phase?

Treating an infection before a pathogen is identified (the first stage/level of abx treatment)

How is empiric therapy selected?

• Using the hospital’s antibiogram

• Assessing what is the likely pathogen to cause an infection

What is de-escalation therapy?

• Moving from broad-spectrum abx treatment to more narrow spectrum

• Occurs after the empiric therapy phase but before the directed therapy phase.

What is definitive therapy?

Abx therapy tailored to a specific pathogen (5 D’s)

What are the CDC Core Elements of Hospital Antibiotic Stewardship Programs?

• Leadership Commitment: Dedicate necessary human, financial and information technology resources

• Accountability: Appoint a leader or co-leaders (pharmacist and physician) responsible for program

• Drug Expertise: Appoint a pharmacist leader (ideally as co-lead) to lead implementation efforts

• Action: Implement interventions

• Tracking antibiotic prescribing, outcomes, resistance

• Reporting information on antibiotic use and resistance to clinicians and hospital leadership

• Educating clinicians about adverse reactions from antibiotics, resistance, and optimal prescribing

Who is involved in the stewardship team?

• Pharmacists (ID pharmacist core member)

• Physician groups (ID physician core member)

• Clinical microbiology

• Nursing

• Infection control/epidemiology

• Administration

• Information technology

• Others as needed

• Form an anti-infective/stewardship committee – A collaboration of minds, institutional influence

Dr. Gross separates opportunities to improve anti-infective use into 2 strategies: what are they?

1) Core strategies

2) Supplemental strategies

What are the core strategies to improve anti-infective use? (2)

• 1. Formulary management

  • Restrictions

  • Preauthorization

• 2. Prospective audit with intervention & feedback

What does formulary management involve?

• Assessment anti-infective formulary and modifying accordingly:

  • Any redundant agents?

  • Most effective agents?

    • Least toxic agents?

  • Most cost-effective agents?

    • Availability of new generics within class?

  • Newly available agents?

    • Are there new data that suggest a better alternative

How do restrictions and pre-authorizations play into formulary management?

• Anti-infective restrictions

  • Pre-authorization challenges:

    • Available staff resources and coverage

    • Pagers/documentation of approval

    • Challenge to physician autonomy

    • Preventing delays in therapy with pre-authorization

      • Potential solutions to challenges: leverage CPOE, establish procedures for after-hours, have policy approve by medical executive committee

  • Criteria-based restrictions vs ID consultation-based restrictions

What are the two main types of restrictions involved in formulary management?

1) Criteria-based restriction

2) ID consultation-based restrictions

What are the supplemental strategies to improve anti-infective use?

• 1) IV to PO switch

• 2) Indications & durations

• 3) Education

• 4) Dosing protocols (including PK/PD optimization through alternative dosing schemes)

• 5) Guideline development

• 6) Use of computerized physician order entry (CPOE) and clinical decision support (CDS)

What is IV → PO Switch?

• If there are a highly bioavailable alternative for agent (and patient is hemodynamically stable and has functioning GI tract) switch from IV to PO

  • This is not limited to only anti-infective drugs!

What is the mechanism for IV → PO switch?

• Set Computer reminders

  • Alert fired when medication ordered

• Automatic switches - Based on pre-determined criteria

• Pharmacist review

• Challenges: identifying patients, implementing change

  • Solution: mine CPOE data to identify patients or use clinical decision support software, approve guideline/protocol specifying clinical criteria

What are benefits of IV → PO switch?

• Decreased length of stay

• Decreased cost

• Potential for discontinuation of IV line (catheter-related bloodstream infection risk, line-related VTE risk, etc)

What is antimicrobial timeout and when should it be used?

• Antimicrobial time-out at 48h-96h to reassess need for continued therapy

• By this time, patient picture more clear, microbiology results available, etc.

  • Transition from empiric therapy to definitive therapy

What are pharmacist led dosing protocols for changing therapy?

• Renal dosing protocols

• Extended-infusion beta-lactams (Time/MIC)

• Pharmacy-managed pharmacokinetic service

  • Education and competency

• Therapeutic substitutions

• Alternative dosing schemes

  • E.g. 1g q6h cefepime instead of 2g q8h

  • 500mg q6h meropenem instead of 1g q8h

What is guideline implementation?

• Integration of national guidelines and institutional antibiogram, formulary, policy, patient population

• Get input and buy-in from specialties dealing with the patient population

• Distribution

  • Charts, electronic, CPOE, education of new medical residents/pharmacists (make sure people know about the guidelines!)