Download Antimicrobial Stewardship

Robert G. Sawyer- University of Virginia
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 What
it means
 Effects on outcomes
 How frequently is it
implemented
 Notes on de-escalation
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A physician
A pharmacist
A clinical microbiologist
An infection preventionist
Dellit TH et al, Clin Infect Dis 2007
SHEA/IDSA/PIDS statement, Infect Cont Hosp Epidemiol 2012
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Prospective audit with intervention and feedback.
Prospective audit of antimicrobial use with direct
interaction and feedback to the prescriber,
performed by either an infectious diseases
physician or a clinical pharmacist with infectious
diseases training, can result in reduced
inappropriate use of antimicrobials
Formulary restriction and preauthorization.
Formulary restriction and preauthorization
requirements can lead to immediate and
significant reductions in antimicrobial use and
cost
Dellit TH et al, Clin Infect Dis 2007
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Education
Guidelines and clinical pathways
Antimicrobial cycling
Antimicrobial order forms
Combination therapy
Streamlining or de-escalation of therapy
Dose optimization
Parenteral to oral conversion
Dellit TH et al, Clin Infect Dis 2007
Nowak MA et al, Am J Health Syst Pharm 2012
Nowak MA et al, Am J Health Syst Pharm 2012
Nowak MA et al, Am J Health Syst Pharm 2012
Standiford HC et al, Inf Cont Hosp Epidemiol 2012
Valiquette L et al, Clin Infect Dis 2007
Boyles TH et al, PLOS One 2013
Boyles TH et al, PLOS One 2013
Teo J et al, Eur J Clin Microbiol Infect Dis 2012
Doron S et al, Clin Ther 2013
Doron S et al, Clin Ther 2013
Yam P et al, Am J Health Syst Pharm 2013
Yam P et al, Am J Health Syst Pharm 2013
Yam P et al, Am J Health Syst Pharm 2013
Linkin DR et al, Infect Cont Hosp Epidemiol 2007
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Removing one of multiple antimicrobials that
is unnecessary, e. g., stopping empiric
vancomycin when an infection is found to be
caused by Pseudomonas aeruginosa
Exchanging one antimicrobial active against
an isolated pathogen for another one also
active but with a narrower spectrum, e. g.,
change piperacillin-tazobactam to
ciprofloxacin for an E. coli infection sensitive
to both agents
Eachempati SR et al, J Trauma 2009
Eachempati SR et al, J Trauma 2009
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Withdrawal of one antimicrobial (group I)
Withdrawal of two of the antimicrobials
empirically prescribed (group II)
Switch to a new antimicrobial with narrower
spectrum (group III)
Withdrawal of at least one antimicrobial plus
change of another drug to a new one with
narrower spectrum (group IV)
Garnacho-Montero J et al, Intensive Care Med 2014
Garnacho-Montero J et al, Intensive Care Med 2014
Garnacho-Montero J et al, Intensive Care Med 2014
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Takes a fair amount of work
Several ways to do it
Less antimicrobial use ⇒ Saves money
Different antimicrobial use patterns
Probably less C. difficile
Rearranges resistance
Same length of stay
Same number of pine boxes
 It’s
worth it