Antimicrobial Stewardship Interventions: Thinking Inside and Outside the Box

Key points

Antimicrobial stewardship ward rounds

Many health care facilities have moved from a more tightly restricted system requiring preprescription authorization to a model that incorporates less restricted antimicrobial use up front but coupled with prospective audit and feedback, also know as postprescription review and feedback. Prospective audit and feedback to providers can be an effective method to improve judicious antimicrobial use. Many studies have shown significant reductions in inappropriate antimicrobial use, increases in

Improving the efficiency of prospective audit and feedback

Prospective audit and feedback can be daunting. The rate of inappropriate antibiotic use is estimated to range between 14% and 43% of all prescriptions.¹¹ It is estimated that the average hospital uses 839 antibiotic days of therapy per 1000 patient-days; there are almost enough antibiotics for every hospitalized patient to receive a full daily dose of an antibiotic each day.¹² The ability to effectively identify patients for prospective audit and feedback has prevented many centers from

Antimicrobial stewardship and antibiotic allergies

Often neglected but imperative considerations in antimicrobial stewardship are antibiotic allergies. Medication allergies are common, and of all antibiotic allergies penicillin is the most common, reported in 5% to 10% of patients.²⁰ When treated for infections, patients with reported penicillin allergies often receive broader-spectrum, suboptimal, and even more toxic agents than patients without reported penicillin allergies. In addition, many alternative agents to β-lactams such as vancomycin

Antimicrobial stewardship at transitions in care

One area that has largely been excluded from stewardship interventions are transitions of care from one setting to another. It has long been recognized that patients are particularly vulnerable when they change from one patient care location to another or to home. Mistakes are often made when preparing a patient’s discharge medications. These pervasive mistakes include incorrect dosage, incorrect therapeutic drug monitoring, incorrect duration, and incorrect medication choice. Furthermore,

Antimicrobial stewardship at the end of life

Hospice promotes palliative care for patients who are terminally or seriously ill, and provides a noble way for these patients to approach the end of life. This philosophy of medical care shifts focus from aggressive treatments and diagnostic procedures to comfort. In this setting, medications and procedures that do not align with this philosophy are discontinued. As in almost all other health care settings, however, antimicrobial agents are perceived differently from other medications and are

Stewardship at the level of prescriber or unit

Guidelines and recommendations for antimicrobial stewardship have focused on the creation of centralized processes and infrastructure to promote judicious antimicrobial use (see Table 1). These programs generally require dedicated and trained personnel to regulate and monitor antimicrobial use. Many health care facilities lack resources and dedicated personnel to perform stewardship activities; therefore, stewardship is limited in most health care facilities. However, it may not be necessary to

Summary

Imprudent antimicrobial use is pervasive in the current health care environment. Relying on traditional methods of antimicrobial stewardship alone will not significantly limit inappropriate antibiotic use in the myriad health care settings. Identifying the areas where most inappropriate antibiotic use exists allows antimicrobial stewardship teams to leverage their resources most efficiently. Electronic alerts can broaden the scope of the audit process but also allow centers without significant