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Antimicrobial Stewardship. St. Mary’s Hospital Infection Control Committee. What is Antimicrobial Stewardship. An interdisciplinary team dedicated to practices that improve appropriate selection, dosing, route, and duration of antimicrobial therapy

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antimicrobial stewardship

Antimicrobial Stewardship

St. Mary’s Hospital

Infection Control Committee

what is antimicrobial stewardship
What is Antimicrobial Stewardship
  • An interdisciplinary team dedicated to practices that improve appropriate selection, dosing, route, and duration of antimicrobial therapy
  • The ultimate goal of antimicrobial stewardship is to improve patient care and health care outcomes
antimicrobial stewardship team
Antimicrobial Stewardship Team
  • Infectious Disease Physician
  • Clinical Pharmacist
  • Clinical microbiologist
  • Information System Specialist
  • Infection control professional
  • Hospital epidemiologist
  • Leadership support
elements of an antimicrobial stewardship team
Elements of an Antimicrobial Stewardship Team
  • A comprehensive program will include:
    • Active monitoring of resistance
    • Fostering of appropriate antimicrobial use
    • Collaboration with an effective infection control program to minimize secondary spread of resistance is considered optimal
elements of an antimicrobial stewardship program
Elements of an Antimicrobial Stewardship Program
  • Prospective audit with intervention and feedback
  • Formulary restriction and preauthorization
  • Guidelines and clinical pathways
  • Antimicrobial cycling
  • Antimicrobial Order Forms
  • Monitoring of progress and outcome measures
  • Education
  • De-escalation of therapy
  • Dose optimization
  • Conversion from parenteral to oral
  • Computer Surveillance/Decision Support
  • Microbiology Laboratory
prospective audit intervention and feedback
Prospective audit,intervention,and feedback
  • Have the clinical pharmacist on the floor making recommendations about appropriate antibiotic, route, length of therapy
  • Probiotic Protocol to prevent C. Diff
  • Focus on one floor for recommendations
  • Up to a 37% reduction in the number of days of inappropriate antibiotic use.Approx. $400.00 cost savings per patient
  • While assessing patients for probiotics look at de-escalating of antibiotics
  • Decrease rate of C. Diff
formulary restriction and preauthorization requirements for specific agents
Formulary restriction and preauthorization requirements for specific agents
  • Control of certain antibiotic use through Pharmacy and Therapeutics Committee can be very effective
  • Control of Cleocin use has led to prompt cessation of nosocomial outbreak of C. Diff
  • Restriction of Vancomycin and third generation cephalosporins in response to VRE has demonstrated mixed results
  • Conference Presentations
  • Student teaching
  • E-mail alerts
  • Provision of written guidelines
  • Peri-operative area order forms
  • Share results of audits
guidelines and clinical pathways
Guidelines and Clinical Pathways
  • Implementation of guidelines incorporating local microbiology and resistance patterns
  • Balance antibiotics in HAP and VAP patients
  • Use algorithms incorporating the clinical pulmonary infection score
  • Leads to decreased duration of therapy,decreased VAP recurrence, decrease of multi-drug resistance patterns
antimicrobial cycling
Antimicrobial Cycling
  • Slows spread of resistance
  • Most popular is Gentamicin to Amikacin
  • Ceftazadime for Ciprofloxacin lead to a decreased incidence of VAP
antimicrobial order forms
Antimicrobial Order Forms
  • Use of Peri-operative prophylactic order forms with automatic stop at 2 days (SCIP Guidelines)
  • Pneumonia Order set (Pneumonia core measures) with 6 different pneumonia indications and drugs
  • Order forms facilitate implementation of practice guidelines
streamlining or de escalation of therapy
Streamlining or De-Escalation of therapy
  • Continuing excessive broad therapy contributes to the selection of antimicrobial resistant pathogens
  • When culture results become available we can streamline or de-escalate antimicrobial therapy to more targeted therapy that decreases antimicrobial exposure and contains cost
  • This can also lead to avoidance of redundant inpatient antibiotic- days
dose optimization
Dose Optimization
  • Dosing that accounts for individual patient characteristics (age,weight,renal function)
  • Site of infection
  • Pharmacokinetics -Vancomycin and aminoglycosides
  • Optimize antimicrobial pharmacodynamics of the drugs B-lactams and fluoroquinolones
conversion from parenteral to oral therapy
Conversion from parenteral to oral therapy
  • Having a systematic plan for switching from parenteral to oral treatment may have an added benefit of aiding in early hospital discharge planning
  • Development of clinical criteria and guidelines allowing conversion can facilitate implementation.
computer surveillance microbiology
Computer Surveillance / Microbiology
  • Add cost codes to antimicrobial susceptibility data
  • Antimicrobial report to pharmacy
  • Vancomycin dosing/utilization sheet
  • Review antimicrobial errors
  • Leap frog to CPOE
  • Actively involved in resistance surveillance
  • Update antibiogram annually
  • Make easily accessible to physicians
st mary s antibiotic stewardship efforts to date
St.Mary’s Antibiotic Stewardship Efforts to Date
  • Probiotic Protocol
  • Antibiogram on line
  • Pneumonia Order sets
  • Pharmacokinetics
  • Peri-op Area Guidelines
  • IV to PO conversion
  • Culture results from lab
  • Pharmacy/IS generated pneumonia vaccine program
what does our future hold for antibiotic stewardship
What does our future hold for Antibiotic Stewardship
  • Assign antibiotic rounds to new pharmacy school professor ( de-escalating and streamlining)
  • Follow culture results from lab
  • Approve IV to PO conversion automatic by pharmacist
  • Finish 6 month Probiotic study
  • Work on Vancomycin Order form

Documentation of Interventions by type


Total Antibiotic Interventions:100

Percent Accepted: 85%

  • April Ecker and Gin Fleming (Antibiotic Pharmacist)
c h e act initiatives thru september 2013
C.H.E. Act Initiatives Thru September 2013

Anti-infectives (Antibiotics)


Proton Pump Inhibitors

Asthma Drugs