Antimicrobial Stewardship

what is antimicrobial stewardship?

the effort to measure and improve how antibiotics are prescribed by clinicians and used by patients

who requires that all hospitals and nursing care centers have an antimicrobial stewardship program

the Joint Commission

define antibiotic resistance

microbes’ natural ability to evolve genetically to counter the effectiveness of medications

what are the CDC’s 7 core elements of antibiotic stewardship

hospital leadership commitment, accountability, pharmacy expertise, action, tracking, reporting, and education

hospital leadership committment role in antimicrobial stewardship

help programs obtain necessary resources to accomplish its goals, P & T committees play a key role in helping to develop and implement policies that will improve antibiotic use

role of accountability in antimicrobial stewardship

programs have a designated leader or co-leaders who are accountable for management of the program and its outcomes - most are led by both a physician and pharmacist

purpose of pharmacy expertise in antimicrobial stewardship:

highly effective improving antibiotic use and often help lead programs in larger hospitals and healthcare systems

which antibiotic stewardship interventions in hospital are the most effective?

published evidence demonstrates that prospective audit and feedback (post-prescription review) and preauthorization

what is prospective audit and feedback

trained staff review antimicrobial orders and provide written/verbal recommendations to providers - does not delay first dose and acceptance of antibiotic recommendations is voluntary

what is preauthorization?

approval from an ID pharmacist/physician before administration of certain antimicrobial agents '“ID approval only” - allows for interventions and educations about appropriate antimicrobial use

examples of restricted antimicrobials

broad spectrum or “big gun” antimicrobials, costly antimicrobials, antimicrobials on shortage

how can we intervene for common infections needed antibiotics?

optimize the duration of therapy, tailor therapy to culture results

interventions utilized in UTIs

not treating asymptomatic bacteriuria, avoiding unnecessary urine cultures, and ensuring appropriate therapy based on local susceptibilities for shortest duration of therapy that is clinically indicated

what interventions can be used in SSTIs?

prescribing the correct route, dosage, and duration of treatment (most uncomplicated skin infections can be treated for 5 days); avoid broad spectrum antibiotics in uncomplicated infections

examples of pharmacy based interventions:

documentation of indications for antibiotics, automatic changes from IV to PO antibiotic therapy, dose adjustments, dose optimization, and duplicative therapy alerts (overlapping spectra)

what is tracking?

monitoring antimicrobial use and resistance patterns

what is reporting?

report information on antimicrobial use and resistance regularly to hospital personnel and leadership

examples of clinician education in antimicrobial stewardship:

regular updates on resistance patterns and targeted presentations

examples of patient education in antimicrobial stewardship:

antibiotic education for patients and their caregivers/family.

T/F: education is most effective when paired with interventions and measurement of outcomes

true

rules for initiating empiric therapy

obtain cultures before empiric treatment if clinically appropriate - empiric treatment should be based on local resistance patterns and should target the most common pathogens and their anatomic source; use the narrowest spectrum drug for pathogen if cultures/susceptibility results

which drugs have good oral bioavailability (direct IV to Po conversion)?

macrolides, FQs, metronidazole, doxycycline, linezolid, TMP/SMX

which antibiotics do not need renal dose adjustments?

ceftriaxone, oxacillin, moxifloxacin, metronidazole, azithromycin, nafcillin, doxycycline, linezolid, dalfopristin/quinapristin, tigecycline, erythromycin, clindamycin

what to do for patients with severe penicillin allergies (anaphylaxis, SOB, hives)

use alternative agent or desensitize patient if no other acceptable non-BL options are possible

what to do for patients with non-severe penicillin allergies (rash)?

some providers may feel comfortable challenging a patient with a cephalosporin or carbapenem (BL family)

drugs for MSSA

anti-staphylococcal penicillins (dicloxacillin, nafcillin, oxacillin) and 1st generation cephalosporins (cefazolin IV, cephalexin PO)

drugs for MRSA

vancomycin, linezolid, daptomycin, ceftaroline, clindamycin, doxycycline, Bactrim, dalbavancin, oritavancin, tigecycline, delafloxacin, quinupristin/dalfopristin

drugs for streptococci

penicillins, cephalosporins, vancomycin, moxifloxacin, levofloxacin

which drug is not a respiratory FQ and does not cover streptococcus pneumoniae?

ciprofloxacin

drugs for enterococci

ampicillin, amoxicillin, daptomycin, linezolid, vancomycin, fosfomycin (UTI ONLYYYY)

which drugs should be avoided in enterococci

cephalosporins, Bactrim, FQs, and ertapenem

what does ertapenem not cover?

Acinetobacter, pseudomonas, enterococci

drugs for pseudomonas

pip/taz, cefepime, ceftazidime ± avibactam, ceftolozane/tazobactam, doripenem, imipenem/cilastatin, meropenem, fosfomycin (UTI ONLY), aminoglycosides (Amikacin, tobramycin, gentamicin), FQs

what are the only oral options for pseudomonas?

FQs!!! cipro and levo (moxifloxacin DOES NOT COVER)