Toolkit for Reduction of Clostridium difficile Infections Through Antimicrobial Stewardship

Ø Resource 2F: A Comparison of Potential Antimicrobial Stewardship Interventions

Purpose: A tool to review types of antimicrobial stewardship interventions, comparing strengths and weaknesses and providing examples.

Source: Developed by B. Ostrowsky and S. Brown, Montefiore Medical Center, for ERASE C. difficile Project toolkit.

Instructions: Use when choosing and implementing targeted interventions.

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.

1. Traditional methods such as intravenous to oral switch programs and dose optimization may be used by a well-rounded antimicrobial stewardship team, but on their own will likely not be effective interventions directed at decreasing C. difficile infection.

2. Categories adapted from  Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. Guidelines for Developing an Institutional Program To Enhance Antimicrobial Stewardship (PDF File).

Return to Question 2

Page last reviewed September 2012
Page originally created September 2012
Internet Citation: Ø Resource 2F: A Comparison of Potential Antimicrobial Stewardship Interventions. Content last reviewed September 2012. Agency for Healthcare Research and Quality, Rockville, MD.