Visit the Get Smart website to learn more. Read the article. Antimicrobial stewardship targeted to C. The goal of this toolkit is to assist hospital staff and leadership in developing an effective ASP with the potential to reduce C.
Published evidence demonstrates that prospective audit and feedback sometimes called post-prescription review and preauthorization are the two most effective antibiotic stewardship interventions in hospitals Prospective audit and feedback is an external review of antibiotic therapy by an expert in antibiotic use, accompanied by suggestions to optimize use, at some point after the agent has been prescribed Audit and feedback can be implemented in a variety of ways, depending on the level of expertise available.
Stewardship programs with limited infectious diseases expertise might choose to focus reviews on comparing prescribed treatment courses to recommendations in hospital specific treatment guidelines and focus on common conditions, such as community-acquired pneumonia, urinary tract infection, or skin and soft tissue infection.
Programs with more advanced infectious diseases expertise might elect to review more complex antibiotic treatment courses. Preauthorization requires prescribers to gain approval prior to the use of certain antibiotics. This can help optimize initial empiric therapy because it allows for expert input on antibiotic selection and dosing, which can be lifesaving in serious infections, like sepsis.
It can also prevent unnecessary initiation of antibiotics Decisions on which antibiotics to place under preauthorization should be made in consultation with providers to focus on opportunities to improve empiric use, rather than on drug costs This intervention requires the availability of expertise and staff who can complete authorizations in a timely manner Hospitals can tailor the agents, situations, and mechanisms e.
Stewardship programs should monitor potential unintended consequences of preauthorization, especially treatment delays. Two studies have compared these two interventions directly and found prospective audit and feedback to be more effective than preauthorization 42 , However, many experts suggest that these interventions should both be priorities for implementation since preauthorization can help optimize initiation of antibiotics and prospective audit and feedback can help optimize continued therapy.
Facility specific treatment guidelines are also considered a priority because they can greatly enhance the effectiveness of both prospective audit and feedback and preauthorization by establishing clear recommendations for optimal antibiotic use at the hospital.
These guidelines can optimize antibiotic selection and duration, particularly for common indications for antibiotic use like community-acquired pneumonia, urinary tract infection, intra-abdominal infection, skin and soft tissue infection and surgical prophylaxis. Recommendations may be based on national guidelines but should reflect hospital treatment preferences based on local susceptibilities, formulary options, and patient mix. Ideally, the recommendations should also address diagnostic approaches, such as when to send diagnostic samples and what tests to perform, including indications for rapid diagnostics and non-microbiologic tests e.
The development of treatment guidelines is a good way for the stewardship program to engage prescriber stakeholders to develop consensus on antibiotic use. Stewardship programs can prioritize the development of guidelines based on the infections most commonly encountered. Adherence to hospital guidelines can be enhanced by embedding treatment recommendations in order sets and clinical pathways. More than half of all antibiotics given to treat active infections in hospitals are prescribed for three infections where there are important opportunities to improve use: lower respiratory tract infection e.
Optimizing the duration of therapy can be especially important because many studies show infections are often treated for longer than guidelines recommend and data demonstrate that each additional day of antibiotics increases the risk of patient harm 4 , Examples of interventions are below and summarized in Table 1.
Optimizing the duration of therapy at hospital discharge is especially important as most excess antibiotic use in the treatment of community-acquired pneumonia occurs after discharge 48 , Urinary tract infection UTI : Many patients who are prescribed antibiotics for UTIs have asymptomatic bacteriuria that generally does not need to be treated.
Successful stewardship interventions focus on avoiding obtaining unnecessary urine cultures and avoiding treatment of patients who are asymptomatic, unless there are specific reasons to treat For patients who need treatment, interventions can focus on ensuring patients receive appropriate therapy based on local susceptibilities for the recommended duration Skin and soft tissue infection: Interventions have focused on ensuring patients with uncomplicated infections do not receive antibiotics with overly broad spectra e.
Data also suggest that negative results of MRSA nasal colonization testing can help guide decisions to discontinue empiric therapy for MRSA pneumonia For patients with urinary catheters, avoid obtaining urine cultures based solely on cloudy appearance or foul smell in the absence of signs and symptoms of UTI.
Nonspecific signs and symptoms such as delirium, nausea and vomiting should be interpreted with caution as, by themselves, they have a low specificity for UTI. Avoid antibiotic therapy for asymptomatic bacteriuria except in certain clinical situations where treatment is indicated, such as for pregnant women and those undergoing an invasive genitourinary procedure. Use of therapy specific for MRSA may not be necessary in uncomplicated non-purulent cellulitis Sepsis: Early administration of effective antibiotics is lifesaving in sepsis.
Antibiotic stewardship programs should work with sepsis experts in the hospital, along with the pharmacy and microbiology lab, to optimize the treatment of sepsis. Important issues to address are:. Studies have also shown that treatment protocols and, where available, infectious diseases consultation, can improve outcomes in patients with S.
Reviewing antibiotics in patients with new diagnoses of C. Stewardship programs can also make sure that patients are receiving guideline recommended therapy for their C. Culture proven invasive infection: Invasive infections e.
Prospective audit and feedback of new culture or rapid diagnostic results may be particularly beneficial to reduce the time needed to discontinue, narrow, or broaden antibiotic therapy as appropriate. Review of planned outpatient parenteral antibiotic therapy OPAT : In some cases, OPAT can be optimized or even avoided altogether following a review by the antibiotic stewardship program However, providers often do not revisit the selection of the antibiotic after more data including culture results become available.
An antibiotic timeout is a provider-led reassessment of the continuing need and choice of antibiotics when the clinical picture is clearer and more diagnostic information, especially results of cultures and rapid diagnostics, is available. Antibiotic timeouts are different from prospective audit and feedback because the providers, not the stewardship team, are doing the reviews. A trial demonstrated that antibiotic timeouts at hours of therapy improved the appropriateness of antibiotic selection, but did not reduce overall antibiotic use Antibiotic timeouts are a useful supplemental intervention but should not be considered a substitute for prospective audit and feedback by the stewardship program.
The optimal timing of antibiotic timeouts has not been established. Experts suggest that daily reviews of antibiotic selection, until a definitive diagnosis and treatment duration are established, can optimize treatment. Provider-led reviews of antibiotics can focus on four key questions 67 :. There are several effective approaches to properly assess penicillin allergies, including history and physical examination, challenge doses, and skin testing 69 , Nurses may be able to play an important role in improving penicillin allergy assessments The microbiology lab in consultation with the stewardship program often implement the following interventions:.
Measurement is critical to identify opportunities for improvement and to assess the impact of interventions. Measurement of antibiotic stewardship interventions may involve evaluation of both processes and outcomes.
For example, a program will need to evaluate if policies and guidelines are being followed as expected processes and if interventions have improved patient outcomes and antibiotic use outcomes. There are a variety of health information technology companies that can facilitate the reporting of antibiotic use data to the AU Option Stewardship programs can work with their information technology staff to explore options for reporting data to the AU Option.
The NHSN AU Option provides rates of antibiotic use expressed as days of therapy DOTs per days present for nearly all antibiotics for individual inpatient care locations, select outpatient care locations e.
Days of therapy are the sum of days for which any amount of a specific antibiotic agent is administered to a patient. SAARs were developed for a variety of groups of antibiotics for both adult, pediatric and neonatal care locations in response to suggestions from stewardship experts on the types of data that would be most actionable Hospitals that are not yet reporting to the NHSN AU Option can often get antibiotic use data from their pharmacy record systems, usually either as days of therapy or as defined daily doses DDDs.
The DDD estimates antibiotic use in hospitals by aggregating the total number of grams of each antibiotic purchased, ordered, dispensed, or administered during a period of interest divided by the World Health Organization-assigned DDD United States guidelines recommend the use of days of therapy rather than DDDs as the preferred numerator metric for hospital antibiotic use Most acute care hospitals are already monitoring and reporting information on C.
Antibiotic Resistance. Improving antibiotic use is important to reduce antibiotic resistance and presents another option for measurement. The development and spread of antibiotic resistance is multi-factorial and studies assessing the impact of improved antibiotic use on resistance rates have shown mixed results 7 , 87 , The impact of stewardship interventions on resistance is best assessed when measurement is focused on pathogens that are recovered from patients after admission when they are under the influence of hospital stewardship interventions Monitoring resistance at the patient level i.
Financial Impact. Stewardship programs can achieve significant cost savings, particularly drug cost savings. If hospitals monitor antibiotic costs, they should assess the pace at which antibiotic costs were rising before the start of the stewardship program After an initial period of marked savings, costs often stabilize. However, it is important to continue support for stewardship programs since costs can increase if programs are terminated Process measures can focus on the specific interventions being implemented at the hospital.
Priority process measures include:. Antibiotic stewardship programs should provide regular updates to prescribers, pharmacists, nurses, and leadership on process and outcome measures that address both national and local issues, including antibiotic resistance.
Summary information on antibiotic use and resistance along with antibiotic stewardship program work should be shared regularly with hospital leadership and the hospital board. Findings from medication use evaluations along with summaries of key issues that arise during prospective audit and feedback reviews and preauthorization requests can be especially useful to share with prescribers. Sharing facility-specific information on antibiotic use is a tool to motivate improved prescribing, particularly if wide variations in the patterns of use exist among similar patient care locations Provider specific reports with peer comparisons have been effective in improving antibiotic use in outpatient settings 95 , but there is limited experience with these reports for hospital-based providers.
CDC has a variety of educational resources, including a Training on Antibiotic Stewardship that includes a module focused on improving antibiotic use in hospitals Education is a key component of comprehensive efforts to improve hospital antibiotic use; however, education alone is not an effective stewardship intervention There are many options for providing education on antibiotic use such as didactic presentations, which can be done in formal and informal settings, messaging through posters, flyers and newsletters, or electronic communication to staff groups.
Education is most effective when paired with interventions and measurement of outcomes. Case-based education can be especially powerful, so prospective audit with feedback and preauthorization are both good methods to provide education on antibiotic use. This can be especially effective when the feedback is provided in person, for example through handshake stewardship.
Some hospitals review de-identified cases with providers to help identify changes in antibiotic therapy that could have been made. Education is most effective when tailored to the action s most relevant to the provider group, such as education on community acquired pneumonia guidelines for hospitalists or education on culture techniques for nurses. They should be engaged in developing educational materials and educating patients about appropriate antibiotic use. Patient education is also an important focus for antibiotic stewardship programs.
It is important for patients to know what antibiotics they are receiving and for what reason s. They should also be educated about adverse effects and signs and symptoms that they should share with providers. Patients should be alerted to side effects that may occur after they have been discharged and even after they have stopped taking antibiotics. Engaging patients in the development and review of educational materials can make these items more effective.
Nurses are an especially important partner for patient education efforts. The Core Elements of Hospital Antibiotic Stewardship Programs is one of a suite of documents intended to help improve the use of antibiotics across the spectrum of health care. Building upon the hospital Core Elements framework, CDC also developed guides for other healthcare settings:. CDC will continue to use a variety of data sources, including the NHSN annual survey of hospital stewardship practices and AU Option, to find ways to optimize hospital antibiotic stewardship programs and practices.
CDC will also continue to collaborate with an array of partners who share a common goal of improving antibiotic use. With stewardship programs now in place in most US hospitals, the focus is on optimizing these programs. CDC recognizes that research is essential to discover both more effective ways to implement proven stewardship practices as well as new approaches.
CDC will continue to support research efforts aimed at finding innovative solutions to stewardship challenges. Skip directly to site content Skip directly to page options Skip directly to A-Z link. Antibiotic Prescribing and Use. Section Navigation. Facebook Twitter LinkedIn Syndicate. Minus Related Pages. With the increasing prevalence of antibiotic-resistant organisms and decreased efforts in new antibiotic development, we are slowly running out of options to treat resistant infections.
In order to combat future antibiotic-resistant infections, we must make a serious effort to conserve our existing antibiotics and continue the develpment of new ones. Like all medications, antibiotics have potential side effects. Commonly, they include: upset stomach, nausea, diarrhea, vomiting, rash, oral thrush and vaginal yeast infection.
When taking antibiotics for a long period of time, a person may also develop a Clostridioides difficile infection. In most cases , C. These bacteria produce toxins that can damage the intestines and cause diarrhea, fever and abdominal pain. Email our team at Antimicrobial.
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