Each recommendation includes a ranking for the strength and the quality of evidence supporting it. Definitions of the levels of evidence (I-III) and grades of recommendation (A-C) are repeated at the end of the Major Recommendations field.
Guidelines for Developing An Institutional Program to Enhance Antimicrobial Stewardship
The Antimicrobial Stewardship Team and Administrative Support
- Core members of a multidisciplinary antimicrobial stewardship team include an infectious diseases physician and a clinical pharmacist with infectious diseases training (A-II) who should be compensated for their time (A-III), with the inclusion of a clinical microbiologist, an information system specialist, an infection control professional, and hospital epidemiologist being optimal (A-III). Because antimicrobial stewardship, an important component of patient safety, is considered to be a medical staff function, the program is usually directed by an infectious diseases physician or codirected by an infectious diseases physician and a clinical pharmacist with infectious diseases training (A-III).
- Collaboration between the antimicrobial stewardship team and the hospital infection control and pharmacy and therapeutics committees or their equivalents is essential (A-III).
- The support and collaboration of hospital administration, medical staff leadership, and local providers in the development and maintenance of antimicrobial stewardship programs is essential (A-III). It is desirable that antimicrobial stewardship programs function under the auspices of quality assurance and patient safety (A-III).
- The infectious diseases physician and the head of pharmacy, as appropriate, should negotiate with hospital administration to obtain adequate authority, compensation, and expected outcomes for the program (A-III).
- Hospital administrative support for the necessary infrastructure to measure antimicrobial use and to track use on an ongoing basis is essential (A-III).
Elements of an Antimicrobial Stewardship Program
Active Antimicrobial Stewardship Strategies
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 (A-I).
Formulary Restriction and Preauthorization Requirements for Specific Agents
- Formulary restriction and preauthorization requirements can lead to immediate and significant reductions in antimicrobial use and cost (A-II) and may be beneficial as part of a multifaceted response to a nosocomial outbreak of infection (B-II). The use of preauthorization requirements as a means of controlling antimicrobial resistance is less clear, because a long-term beneficial impact on resistance has not been established, and in some circumstances, use may simply shift to an alternative agent with resulting increased resistance (B-II). In institutions that use preauthorization to limit the use of selected antimicrobials, monitoring overall trends in antimicrobial use is necessary to assess and respond to such shifts in use (B-III).
Supplemental Antimicrobial Stewardship Strategies
The following elements may be considered and prioritized as supplements to the core active antimicrobial stewardship strategies based on local practice patterns and resources.
Education
- Education is considered to be an essential element of any program designed to influence prescribing behavior and can provide a foundation of knowledge that will enhance and increase the acceptance of stewardship strategies (A-III). However, education alone, without incorporation of active intervention, is only marginally effective in changing antimicrobial prescribing practices and has not demonstrated a sustained impact (B-II).
Guidelines and Clinical Pathways
- Multidisciplinary development of evidence-based practice guidelines incorporating local microbiology and resistance patterns can improve antimicrobial utilization (A-I). Guideline implementation can be facilitated through provider education and feedback on antimicrobial use and patient outcomes (A-III).
Antimicrobial Cycling and Scheduled Antimicrobial Switch
- There are insufficient data to recommend the routine use of antimicrobial cycling as a means of preventing or reducing antimicrobial resistance over a prolonged period of time (C-II). Substituting one antimicrobial for another may transiently decrease selection pressure and reduce resistance to the restricted agent. Unless the resistance determinant has been eliminated from the bacterial population, however, reintroduction of the original antimicrobial is again likely to select for the expression of the resistance determinant in the exposed bacterial population.
Antimicrobial Order Forms
- Antimicrobial order forms can be an effective component of antimicrobial stewardship (B-II) and can facilitate implementation of practice guidelines.
Combination Therapy; Prevention of Resistance Versus Redundant Antimicrobial Coverage
- There are insufficient data to recommend the routine use of combination therapy to prevent the emergence of resistance (C-II). Combination therapy does have a role in certain clinical contexts, including use for empirical therapy for critically ill patients at risk of infection with multidrug-resistant pathogens, to increase the breadth of coverage and the likelihood of adequate initial therapy (A-II).
Streamlining or De-escalation of Therapy
- Streamlining or de-escalation of empirical antimicrobial therapy on the basis of culture results and elimination of redundant combination therapy can more effectively target the causative pathogen, resulting in decreased antimicrobial exposure and substantial cost savings (A-II).
Dose Optimization
- Optimization of antimicrobial dosing based on individual patient characteristics, causative organism, site of infection, and pharmacokinetic and pharmacodynamic characteristics of the drug is an important part of antimicrobial stewardship (A-II).
Parenteral to Oral Conversion
- A systematic plan for parenteral to oral conversion of antimicrobials with excellent bioavailability, when the patient's condition allows, can decrease the length of hospital stay and health care costs (A-I). Development of clinical criteria and guidelines allowing conversion to use of oral agents can facilitate implementation at the institutional level (A-III).
Computer Surveillance and Decision Support
- Health care information technology in the form of electronic medical records (A-III), computer physician order entry (B-II), and clinical decision support (B-II) can improve antimicrobial decisions through the incorporation of data on patient-specific microbiology cultures and susceptibilities, hepatic and renal function, drug-drug interactions, allergies, and cost. However, implementation of these features has been slow, and conformation of the technology to the clinical environment remains a challenge.
- Computer-based surveillance can facilitate good stewardship by more efficient targeting of antimicrobial interventions, tracking of antimicrobial resistance patterns, and identification of nosocomial infections and adverse drug events (B-II).
Microbiology Laboratory
- The clinical microbiology laboratory plays a critical role in antimicrobial stewardship by providing patient-specific culture and susceptibility data to optimize individual antimicrobial management and by assisting infection control efforts in the surveillance of resistant organisms and in the molecular epidemiologic investigation of outbreaks (A-III).
Monitoring of Process and Outcome Measurements
- Both process measures (did the intervention result in the desired change in antimicrobial use?) and outcome measures (did the process implemented reduce or prevent resistance or other unintended consequences of antimicrobial use?) are useful in determining the impact of antimicrobial stewardship on antimicrobial use and resistance patterns (B-III).
Definitions of Strength of Recommendation and Quality of Evidence Ratings:
Quality of Evidence
- Evidence from at least one properly randomized, controlled trial
- Evidence from at least one well-designed clinical trial without randomization, from cohort or case-control analytic studies (preferably from more than one center), from multiple time-series studies, or from dramatic results of uncontrolled experiments
- Evidence from opinions of respected authorities on the basis of clinical experience, descriptive studies, or reports of expert committees
Strength of Recommendation
- Good evidence to support a recommendation for use
- Moderate evidence to support a recommendation for use
- Poor evidence to support are commendation for use
