Infectious Diseases II

Critical care pharmacists could either have an active role as a member of a multidisciplinary antibiotic

stewardship team or serve in many of the different roles and activities of antibiotic stewardship.

Education with active intervention – Interpretation of rapid identification tests and susceptibility

testing

Guidelines and clinical pathway development. Recent IDSA guidelines recommend facility-

specific clinical practice guidelines or algorithms as an effective way of standardizing prescribing

practices.

Streamlining or de-escalation of therapy

Shortening therapy duration

ii.

Discontinuing unnecessary antimicrobials

Application of PK/PD principles. Per IDSA recommendations, PK and dose-monitoring

programs are specifically recommended for vancomycin and aminoglycosides.

ii.

Dose adjustments based on organ function

iii.

Allergy detection and assessment, in particular promotion of β-lactam skin testing when

appropriate

Parenteral to oral conversion

Recent IDSA guidelines recommend against the use of didactic education alone for stewardship.

Support from microbiology laboratory and electronic medical record system surveillance and clinical

decision support may further enhance stewardship efforts.

Prospective audit with intervention and feedback (“back-end” strategy)

Allows flexibility and minimizes delay in administering therapy

The most successful strategy involves direct communication with treating physicians and required

documentation for acceptance of recommendation or rationale for denial.

May be resource-intensive, and prescribers may feel a loss of autonomy

Initial choices of antimicrobials may be optimized through consultation with infectious disease

experts.

Antimicrobial cycling: An example of formulary restriction in which there is a scheduled removal

and substitution of a specific antimicrobial or an antimicrobial class. It is an effort to minimize

antimicrobial selection pressures. Evidence is insufficient to suggest that antimicrobial cycling

strategies are effective. IDSA stewardship guidelines recommend against the use of antimicrobial

cycling as a stewardship strategy. The compensatory overuse of another class of antibiotics has

been reported when attempts to restrict a different class of antibiotics were implemented.

Regardless of the strategies used or the quality of clinical pathways, programmatic antibiotic stewardship

is not a substitute for clinical judgment.

Process indicators (e.g., days of therapy, provider adherence to clinical pathway, time to effective

therapy) and outcome measures (e.g., LOS, mortality, 30-day readmission) should be used to gauge

program success.

Antimicrobials can account for up to 30% of hospital pharmacy budgets, with up to 50% of antimicrobial

use being inappropriate, leading to increased cost, increased selection of resistant pathogens, and

increased selection of opportunistic infections (OIs).