• Can antibiotic treatment be de-escalated, or switched, to a more targeted antibiotic? • For what duration should the patient receive antibiotics? Pharmacy-driven Interventions Pharmacy staff play a large role in maintaining appropriate antibiotic use, and can implement a number of antibiotic stewardship interventions. Documenting Indications for Antibiotics As pharmacists process antibiotic orders, they are in an ideal position to ensure antibiotic orders include an indication when prescribed. This helps improve antibiotic use and facilitate antibiotic stewardship interventions such as prospective audit and feedback. 13 Automatically Changing Intravenous Antibiotics to Oral Certain antibiotics with good oral absorption can be switched from intravenous administration to oral dosing, if appropriate for a given patient and situation. This allows for improved patient safety by decreasing the need for intravenous access ports. Antibiotics that are often good candidates for switching from intravenous to oral administration include fluoroquinolones, linezolid, and trimethoprim-sulfamethoxazole. Pharmacy staff can work with the clinical team to help convert intravenous to oral antibiotics, as appropriate. 3 Dose Adjustments and Optimization Pharmacy staff play an important role in adjusting dosages of medications in cases of organ dysfunction, such as in patients with reduced kidney or liver function. Pharmacy staff can also recommend dosage adjustments based on therapeutic drug monitoring, achieving penetration of the central nervous system, and optimizing treatment for highly drug-resistant bacteria. 3 Automatic Alerts for Duplicate Therapy Alerts can be programmed to notify users when multiple agents with overlapping spectra of activity are ordered, such as when multiple agents have anaerobic activity, gram-negative activity, or resistant gram-positive activity. 14,15 Time-sensitive Automatic Stop Orders Automatic stop orders can be utilized for antibiotic prescriptions with specific timeframes, such as those used for surgical prophylaxis. Other antibiotic orders can also have pre-programmed stop dates; for example, if an order for Levaquin reads to administer it for seven days, a stop date can be programmed to end the order on the seventh day so that there is no accidental continuation of orders that should have been stopped. 3 Detecting and Preventing Antibiotic-related/Drug- Drug Interactions A key role of pharmacists is to review and prevent drug-drug interactions. Since some antibiotics can interact with other drugs or supplements a patient
may be taking, preventing these interactions can help optimize antibiotic therapy. For example, orally administered fluoroquinolones can interact with certain vitamins; separating their administration times can resolve this issue. 3 Syndrome and Infection-Specific Interventions Interventions that target specific syndromes can be implemented to improve prescribing for these issues. It is important to note that these interventions should not interfere with prompt and effective treatment of severe infections or sepsis. 3 Community-Acquired Pneumonia Interventions that target community-acquired pneumonia often focus on making improvements on recognized problems in therapy. These can include tailoring therapy to culture results, improving accuracy of diagnosis, and ensuring the duration of treatment complies with current guidelines. 3 Urinary Tract Infections (UTIs) The treatment of UTIs can be tricky: Many patients who receive antibiotics for UTIs have asymptomatic bacteriuria and not an acute infection. Interventions that can be applied to UTIs focus on preventing unnecessary urine cultures, avoiding treatment of patients who are asymptomatic, and ensuring that patients receive therapy based on local susceptibilities and for the recommended duration of treatment. 24,25 Skin and Soft Tissue Infections Interventions that can be used for skin and soft tissue infections often focus on making sure patients do not receive antibiotics with overly broad spectra, and making sure antibiotics are taken at the correct dose, route, and duration of treatment. 26,27 Sepsis Since the early use of antibiotics in sepsis treatment can be lifesaving, empiric therapy recommendations should be developed based on local antibiogram data. Protocols to administer antibiotics quickly in patients who are suspected to have sepsis should be utilized. Antibiotic review policies should be in place to ensure empiric antibiotic therapy remains appropriate, and to stop or tailor therapy if needed. 3 Methicillin-Resistant Staphylococcus Aureus (MRSA) Infections In many cases, antibiotic therapy for MRSA can be stopped if the patient does not have an active MRSA infection. Antibiotic therapy can often be switched to a beta-lactam antibiotic if the bacteria is found to be methicillin-sensitive Staphylococcus aureus. 3 Clostridium Difficile Infections Clostridium difficile infections affect more than 500,000 patients annually, and are associated with over 15,000 annual deaths in the United States. 28 Treatment guidelines encourage providers to discontinue unnecessary antibiotics in all patients
with Clostridium difficile i nfections, but this step is frequently skipped. A review of any antibiotics being used in patients with a new Clostridium difficile diagnosis can help to remove any unnecessary antibiotics in these patients. This allows for improvements in the clinical response of Clostridium difficile to treatment, as well as reducing the risk of recurrent Clostridium difficile . 29-31 Treating Invasive Infections Proven by Culture Invasive infections, or those that have spread to the bloodstream, are a good opportunity for antibiotic stewardship interventions since they are easily identified by microbiology results. Culture and sensitivity testing typically provides information necessary to adjust antibiotics or discontinue them depending on growth results. Reviewing culture or diagnostic test results through prospective audit and feedback can help reduce the amount of time needed to narrow, broaden, or discontinue antibiotic treatment. 3 BEFORE MOVING ONTO THE NEXT SECTION, PLEASE COMPLETE CASE STUDY 2 ON THE NEXT PAGE. Tracking and Reporting Antibiotic Use and Outcomes Measuring the use of antibiotics is important in order to identify opportunities for improvement and to assess improvement efforts. Measurement in terms of antibiotic stewardship can include both evaluation of processes and outcomes. 3 Evaluation of Antibiotic Use Processes Periodic assessments of antibiotic use and infection treatment should be performed to evaluate the quality of antibiotic use. The following questions can help guide the evaluation of antibiotic use processes: 3 • Did prescribers apply diagnostic criteria for infections accurately? • Were recommended agents prescribed for a given indication? • Was the indication and expected duration of antibiotic therapy documented? • Were cultures and relevant tests obtained prior to treatment? • Were antibiotic choices modified appropriately in response to microbiological findings? In addition, retrospective chart reviews can be performed to assess whether or not antibiotic use policies are being followed. These can allow reviewers to determine if antibiotics are administered at appropriate times; if antibiotic doses, durations, and indications are documented appropriately; and if therapy reassessments are being performed appropriately. When reviews of antibiotic use processes are performed regularly, the impact of efforts to improve antibiotic use can be assessed. 3
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