Antimicrobial Stewardship

Define bacterial resistance

Bacteria grow in the presence of clinically relevant concentrations of antibiotics

Which form of bacterial resistance is the greatest concern?

Acquired

What are urgent threats of emerging bacterial resistance?

Carbapenem-resistant Acinetobacter

Candida auris

Clostridioides difficile

Carbapenem-resistant Enterobacteriaceae

Drug-resistant Neisseria gonorrhoeae

Why do we need antibiotic stewardship?

Antibiotic overuse and misuse

What are problems with antimicrobial prescribing?

Low threshold for prescribing antimicrobials

Broad-spectrum empiric agents started, but lack of appropriate de-escalation

Use of suboptimal regimens

What are patient consequences of inappropriate therapy?

Inadequate treatment

Adverse effects

Allergic reactions

Superinfections

Selection of problematic pathogens

What are societal consequences of inappropriate therapy?

Antimicrobial resistance

"Collateral damage"

Increased healthcare costs

What are benefits of stewardship?

Improved patient outcomes

Decreased adverse events

Resource optimization

Reduce healthcare costs without sacrificing quality of care

What does the government require in regards to stewardship?

Requires hospitals to establish an antimicrobial stewardship program that meets required elements of performance

What are the CDC core elements of stewardship?

1. Leadership commitment

2. Accountability

3. Drug expertise

4. Action

5. Tracking

6. Reporting

7. Education

What are considered key ASP activities?

Prospective audit with intervention and feedback

Formulary restriction and pre-authorization

What actions can support optimal antibiotic use?

Document indication, dose, and duration

Facility specific guidelines for infectious disease states

Allergy assessment

Pre-authorization required for restricted/protected agents

Prospective audit and feedback (PAF)

What are pharmacy-driven interventions for stewardship?

Automatic changes from IV to PO antibiotics

Dose adjustments/optimization

Automatic alerts in situations where therapy might be unnecessarily duplicative

Time-sensitive automatic stop orders

Detection and prevention of antibiotic-related DDIs

When should a patient be switched from IV to PO antibiotics?

If stable, taking other PO drugs, and no concern for oral absorption

What are benefits of switching from IV to PO antibiotics?

Avoids potential complications of IV therapy and facilitates faster hospital discharge

Which antimicrobial drugs can be administered orally?

Fluoroquinolones

Macrolides

Azole antifungals

Metronidazole

Doxycycline, minocycline

Clindamycin

Linezolid

Rifampin

TMP-SMX

How can antimicrobial doses be optimized?

Renal dose adjustments

Pharmacodynamic optimization

What are the three types of pharmacodynamic optimizations?

Concentration-dependent

Time-dependent

Exposure-dependent

Which antibiotics are concentration-dependent?

Aminoglycosides

Daptomycin

Which antibiotics are time-dependent?

Beta-lactams

Which antibiotics are exposure dependent?

Vancomycin

Fluoroquinolones

Describe preauthorization in regards to stewardship

Certain antibiotics require approval by ID and/or antimicrobial stewardship team

Define prospective audit and feedback (PAF)

Antibiotic "time-outs" and reviews at 48-72 hours for patients on empiric antibiotics

Often broad-spectrum antibiotic

Culture data and patient-specific data typically available at 48-72 hours

What are advantages to using order sets and clinical pathways?

Decreases inappropriate use

Presents an opportunity for education

What are disadvantages to using order sets and clinical pathways?

Voluntary adherence

"Cookie cutter" method

Maintenance of materials

Awareness and access to resources

What process measures are used for tracking and monitoring?

Track antibiotic prescribing, use, and resistance

Documentation by providers

Adherence to guidelines

What outcome measures are used for tracking and monitoring?

Resistance patterns (antibiograms)

C. difficile rates

Clinical success difficult to measure

What are antibiotic use measures for tracking and monitoring?

Days of therapy (DOT)

Standardized antibiotic administration ratio (SAAR)

What is the preferred reporting measure of ASP impact?

Days of therapy (DOT)

What is the goal SAAR?

Goal is to be at 1

Describe DOT

Count each DAY each ANTIBIOTIC is given

Not impacted by dose adjustments

Useful in adults or pediatrics

Can measure overall, unit, or provider specific use