Since the majority of all hospital antibiotic use is driven by community-acquired pneumonia, urinary tract infections, and skin and soft tissue infections, a number of interventions focus on these high-yield targets for improvement. 12 Stopping antibiotics or narrowing the spectrum of therapy in cases where broad spectrum antibiotics are prescribed as initial therapy is a highly recommended focus of antibiotic stewardship programs. To maximize resources, facilities can start by focusing on key antibiotics, such as vancomycin, carbapenems, and piperacillin- tazobactam. Reviewing key antibiotics after about two days of therapy is ideal: Culture results are generally available by this time. Reviews should focus on asking if an antibiotic is still needed. If an antibiotic is needed, does the drug have the narrowest spectrum possible? For how long should the antibiotic be continued? Treatment decisions should ideally be driven by local antibiotic resistance data found in antibiograms. Requiring a diagnosis when prescribing antibiotics can allow facilities to program recommendations into order-entry systems to improve antibiotic use. 13 Pharmacists can complete the following daily activities to support antibiotic stewardship programs: 3,14,15 • Review antibiotic prescribing for duplicative antibiotic therapy. • Assess antibiotic orders for opportunities to convert from intravenous to oral antibiotics. • Monitor for medication safety, such as making dose adjustments in patients with kidney disease. Nurses also play an important role in the implementation of antibiotic stewardship activities. These activities include: 3,16,17 • Ensuring cultures are collected correctly and reviewing culture results with the prescribing physician and pharmacist. • Monitoring the patient’s clinical response to antibiotic therapy and updating the prescribing physician and pharmacist. • Assessing the patient’s oral intake and notifying prescribers or pharmacists of opportunities to convert from intravenous to oral antibiotics. • Educating patients about potential side effects of antibiotics, particularly Clostridium difficile infections. • Reviewing antibiotic use after 48 hours of therapy, and initiating antibiotic timeouts with prescribing physicians and pharmacists. Tracking The collection of data is critical for antibiotic stewardship action assessments. While facilities can choose which metrics to assess on their own, the main goal is to collect data on measures that are meaningful to prescribers, useful for antibiotic stewardship activities, and can be tracked over time to assess for areas of improvement.
Facilities have found success in tracking the following data: 3,18,19 • Days of therapy, or the number of days a patient is on antibiotics, is widely considered to be one of the more useful measures of antibiotic use for antibiotic stewardship purposes. • Adherence to treatment recommendations and use of interventions such as antibiotic timeouts. • Clostridium difficile infections and antibiotic- resistant bugs. • Tracking spending on antibiotics is not recommended as a method of assessing effectiveness of stewardship programs because antibiotic spending does not always correlate with antibiotic use. Implementation strategies for tracking data include: 3 • Submitting antibiotic use and resistance data through the CDC’s Antimicrobial Use and Resistance module. ° If utilizing this program is not possible, calculating defined daily doses or assessing the average daily dose of an antibiotic in a standard patient for the top five commonly used antibiotics can be useful if tracked over time at a given facility. • Monitoring adherence of facility treatment recommendations for the top three infections treated with antibiotics: community-acquired pneumonia, urinary tract infections, and skin and soft tissue infections. If possible, tracking this information by provider can isolate providers who are non-compliant with facility treatment recommendations. • Monitoring the use of antibiotic timeouts to identify areas of improvement. • Performing medication use evaluations and assessing broad-spectrum antibiotic use to review for areas of improvement. • Monitoring the conversions of intravenous- to-oral therapies to assess for missed opportunities. • Assessing for unnecessary duplicate therapy. Reporting Data on antibiotic stewardship program efforts should be reported to physicians, medical staff, and facility leadership. Facilities can discuss reporting options with stakeholders to determine the best format for reporting in a timely manner. Implementation strategies for the core element of reporting include: 3 • Preparing regular reports on measures being tracked and providing this information to appropriate personnel and committees, such as the pharmacy and therapeutics committee, patient safety and quality committees, and facility leadership. • If utilized, provider-specific reports should be shared with individual prescribers.
• Determine how to distribute data, such as through newsletters or emails to staff. Education Education is a critical element in the success of antibiotic stewardship programs. Provider education on antibiotic stewardship practices can help ensure that antibiotic prescriptions are ordered appropriately and follow any recommendations of the stewardship programs. Educating nurses on procedures for interventions critical to the stewardship program, such as reviewing criteria for intravenous to oral antibiotic conversions and criteria for obtaining urine cultures, can contribute to stewardship program success. Patient and family education can also be helpful to allow them to monitor for significant adverse events, such as Clostridium difficile . Implementation strategies for education include: 3 • Communicate antibiotic stewardship updates through communications tools such as employee newsletters, blogs, or the facility website. • Providing targeted annual (at least) education to physicians, pharmacists, and nurses. • Providing one-on-one provider education or coaching. • Initiating regular updates on antibiotic stewardship and drug resistance. • Including antibiotic stewardship education in new physician, pharmacist, and nursing staff orientations as well as credentialing education. • Sharing stories on the effects of antibiotic-use complications on patients’ lives. • Ensuring that patient education materials include information on antibiotics. Implementation of Core Elements in Smaller Facilities Studies have shown that smaller facilities experience difficulties implementing the core elements of antibiotic stewardship programs. After the CDC published the core elements in 2014, over 50% of hospitals with more than 50 beds reported meeting all seven core elements, while only 26% of hospitals with 25 or fewer beds reported meeting all seven core elements. 20 Critical access hospitals and those with smaller sizes experience unique challenges in implementing these recommendations. These challenges are often due to limitations in resources, infrastructure, and staffing. However, antibiotic stewardship remains equally important in smaller settings: Patients in these settings also experience antibiotic resistance and Clostridium difficile infections. Since each facility is unique, antibiotic stewardship leaders must consider implementation options that can be effectively applied to their setting. 20
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