| Intervention Type1,2 |
Advantages |
Disadvantages |
Examples |
|---|
| Formulary changes, restrictions, and preauthorization |
- Effective in decreasing targeted antibiotics.
- Can influence choice of antibiotics before patients receive therapy.
- Has education built into process of discussing therapy choice.
|
- Less evidence as a means of reducing long-term antimicrobial use or outcomes, such as resistance.
- May shift prescribing to alternative agents (e.g., "squeezing the balloon") and resulting resistance/C. difficile.
- Effectiveness dependent on skills of staff making recommendations and reviewing requests.
- Mainly affects initial regimen choice and not length of treatment.
- May be less acceptable to prescribers (viewed as policing antibiotics).
- May involve delays in therapy (to obtain approval).
|
- Restricting empiric use of antibiotics associated with most C. difficile cases (may be whole hospital, for specific patient populations/prescribers).
- Choosing specific drugs for the formulary (e.g., limit multiple/redundant quinolones, carbapenems).
- Mandating Infectious Diseases consultation for specific drugs.
|
| Audit and feedback to providers, including strategies for de-escalating and streamlining antibiotics |
- Has been shown to improve antimicrobial use and outcomes.
- Can be adapted to many hospital environments (including small facilities or facilities with limited resources).
- Can be done a few times per week.
- Facilitates a team approach to patient care.
- Allows intervention in cases of inadequate therapy.
- Allows flexibility of therapy based on patient response and clinical status.
|
- Labor intensive; effectiveness dependent on skill of staff making the recommendation.
- Need systems in place to identify patients on whom intervention can be done (helpful to have information technology [IT] or computer software support) and how best to convey suggestions to prescribers (e.g., verbal, written in medical record).
- Mainly affects length of treatment (depending on when performed, may have variable impact, especially if patients have been on antibiotics for long periods of time).
- May be less acceptable to prescribers (viewed as interfering with prescribing).
|
- Obtaining lists of patients on extended spectrum β-lactams and third/fourth generation cephalosporins at 72 hours and approaching clinicians after chart review for de-escalating antibiotics.
- Targeting cefepime-containing empiric therapy in ICU patients with daily rounds with ICU teams (identifying opportunities to shorten course or streamline therapy).
|
| Flow and algorithms for empiric and streamlined regimens for specific diagnoses or pathogens |
- Improves prescribing, including adapting national guidelines to local microbiology and population.
- Can be multidisciplinary in development.
- Can affect initial antibiotic choice and further tailoring of antibiotic.
|
- Requires an outlay of effort over time to develop and educate in their use.
- Needs to be appropriately disseminated and accepted.
- Needs to be an agreement on therapy by all involved parties.
|
- Protocols for workup and/or empiric regimens for sepsis, community-acquired pneumonia, and urinary tract infections.
|
| Novel approaches to use of technology and stewardship staff |
- Allows interventions to be tailored to unique populations and local microbiology.
- Broadens pool of resources for stewardship activities.
- Allows use of local systems to obtain data and supplement activities.
|
- Shorter track record and less ability to predict impact.
- Outlay of effort by stewardship team and others (e.g., IT).
- Technology costs.
|
- Training clinical pharmacists, pharmacy residents, and infectious disease fellows to prescreen candidates for de-escalation or streamlining initiatives.
- Involving nursing and nursing leadership ("non" prescribers) in stewardship activities.
- Using pharmacy tools, including automated pharmacy technology (e.g., Pyxis Medstation™) to offer and track antibiotic prescribing in the emergency department.
|
| Educational component for clinicians and patients |
- Necessary for prescriber buy-in and prescribing in general.
- Supplements above activities.
|
- Have been less successful on their own; should be coupled with other interventions.
|
- Case-based learning, including how to use algorithms and when and how to de-escalate antibiotics.
- Lectures on antibiotic use.
|
