Antimicrobial Stewardship

What are the “ESCAPE” pathogens

• Enterococcus

• Staphylococcus aureus

• Klebsiella pneumoniae

• Acinetobacter baumanii

• Pseudomonas aeruginosa

• Enterococcus spp.

How has Covid 19 effected Antimicrobial resistance?

• Reduction in death

• Overall increase in ABX use

Define Antimicrobial stewardship

• Limiting inappropriate use

• Optimizing antimicrobial selection, dosing, route, and duration

• Maximize clinical cure or prevention of infection

• Limiting unintended consequences (emergence of resistance, ADR, cost)

What are the 5 rights?

1. Choice of ABX

2. Route

3. Dose

4. Time

5. Duration

Goals of antibiotic stewardship are to increase ______ and decrease_______

good patient outcomes; ABX resistance, C.difficle, and cost

What are the 4 core elements of ABX stewardship?

1. Hospital

2. Outpatient

3. ABX for nursing homes

4. Resource-limited settings

What makes up the core elements for hospital antimicrobial stewardship programs (2019)?

• leadership commitment

• accountability

• pharmacy expertise

• action

• tracking

• reporting

• education

True or false:

leadership commitment requires a formal statement of support from the administration and senior leadership making stewardship a priority

true

What components make up leadership commitment?

• stewardship duties in job descriptions and performance reviews

• protected time for stewardship activities

• Support training and education

• multi-disciplinary participation

What makes up accountability and pharmacy expertise component?

Physician and pharmacist are key players

What are some priority strategies in the action component?

• Prospective audit and feedback

  • Use of guidelines

  • Target specific populations or drugs

• Formulary restriction and preauthorization

  • Restrict antimicrobial use

  • Based on patient factors or drug-specific criteria

What are some advantages to streamlining/de-escalation?

• narrows therapy

• influences future prescribing behavior

• decreases inappropriate use

• reduces ADR

• decrease cost

What are some disadvantages to streamlining/de-escalation?

• prescriber reluctance

• inappropriate narrowing of therapy

What are some strategies to practice antimicrobial stewarship?

• Modify consensus-based recommendations on local practice patterns, resistance trends, formularies

• Develop order sets

• Disseminate

• use of protocols or time-outs/reviews

• PK monitoring with aminoglycosides or vanc

What are some example types of protocols you can see?

• Staph aureus

• C. difficile

• IV to PO

• B-lactam allergy assessments

Why do we optimize ABX dosages?

• optimize efficacy

• reduce emergence and selection of resistance

  • Based on:

    • patient characteristics

    • causative organism

    • site of infection

    • PK/PD

What are some benefits for patients and hospitals for IV to PO conversion protocols?

• Improved patient comfort and mobility

• reduced exposure to nosocomial pathogens

• decreased risk of phlebitis

• lower cost

• decreased length of stay

This is now recommended in B-lactam allergy assessments?

PCN skin testing

• Largely unstudied as primary ASP intervention

How does microbiology stewardship help ASPs?

• Ensure cultures are properly and consistently ordered, collected, and transported

• Resistance surveillance with antibiograms

How are we able to track and report data? (process measures)

Metrics are reviewed bi-monthly and reported to ABX subcommittee or the pharmacy and therapeutics committees

What can we as pharmacist do?

• automatic IV to PO conversions

• renal dosing

• PK services

• avoid duplicate therapies

• automatic stop orders

• detect and prevent ABX-related drug-drug interactions

• monitor shortages

Antimicrobial stewardship is required by _______ and ______

Joint Commission; Centers for Medicare and Medicaid services