Improving antimicrobial prescribing in the acute care setting is complex with multiple strategies that can be deployed by an antimicrobial stewardship program (ASP). How an ASP selects and implements interventions to improve antimicrobial prescribing is dependent on many factors. These factors include hospital size, hospital network status, training and background of ASP team members, time dedicated to stewardship activities, infectious diseases (ID) resources, pharmacist resources (especially ID pharmacists), information technology (IT) resources, and the culture and goals of the hospital. Each ASP is inherently unique and ideally has been molded to function in a specific hospital environment. As such, no “one size fits all” group of interventions, goals, policies, and daily work activities can be deployed with consistent results.
In this chapter, we highlight multiple antimicrobial stewardship (AS) interventions that have been shown to improve antimicrobial prescribing and the care of hospitalized patients. We do not recommend that a hospital implement all interventions immediately as this will cause substantial challenges and confusion. Rather, the selection of specific interventions and the degree in which they are implemented (ie, hospital-wide deployment vs targeting a specific unit) will be dependent on the maturity of the ASP and resources available. The selection of ASP interventions should be based on a clear understanding of the hospital needs and the goals of the ASP. Performing a needs assessment is an efficient and intentional method of identifying areas where an ASP should focus their efforts with new or expanded interventions. The Center for Disease Control and Prevention’s (CDC) Core Elements of Hospital Antibiotic Stewardship Programs Checklist
is one example of a needs assessment that provides a framework to identify hospital ASP opportunities.1
When selecting and implementing AS interventions, we recommend focusing on three key principles (Fig. 45-1
). First, ASPs need to adapt and tailor AS interventions to the resources available. This adaptation will result in a more efficient and sustainable intervention. The interventions highlighted in this chapter have been successful in many hospitals; however, a deployment of the exact intervention in your hospital may not be similarly successful if the specific needs and hospital structure are not taken into consideration. AS interventions need to be tailored to the ASP team’s available time, the availability of ID consultation, the involvement of ID clinicians in ASP activities, electronic health record (EHR) capabilities, and hospital culture. Second, implement AS interventions across the continuum of inpatient care. Opportunities to improve antimicrobial prescribing occur throughout the course of patient’s admission. Using the “4 moments of antimicrobial decision making” as a framework,2
AS interventions can be implemented when (1) clinicians identify infections that will respond to antimicrobials and initiate empiric antimicrobial therapy (empiric selection), (2) proper diagnostic tests and cultures are performed and result (test selection and resulting), (3) stopping or narrowing empiric antimicrobials (de-escalation), and (4) determining the total duration of therapy of antimicrobials (duration of therapy). Ideally, an ASP will implement interventions targeting multiple “moments of antimicrobial decision making” to fully optimize prescribing. Third, engage frontline clinicians when selecting and/or implementing new AS interventions. When developing or implementing any new intervention, it is paramount to understand the attitudes, motivations, and intentions of those whose behavior is the target for change.3
Understanding the pressures and challenges faced by those on the receiving end of your intervention will allow the ASP to tailor interventions so they add value to the clinical team, target concerns of the frontline clinicians, and are perceived positively. In addition, understanding the local physical environment and schedules of your target audience will allow you to implement interventions that provide timely recommendations that are not disruptive to workflow. Engaging frontline clinicians in AS discussions and decisions will foster positive relationships and demonstrate your commitment to improving patient care.
In contrast to the fundamental practices, expanded practices have not yet become standard AS practices for all hospitals. Many of the expanded practices described below have a significant body of evidence to support their practice, but incorporating these interventions into ASPs is often limited by the resources required and specialized knowledge needed. Once hospitals have implemented the fundamental practices of AS, the expanded practices can be evaluated and implemented based on need, expertise, and time available.
Microbiologic testing is a cornerstone of appropriate ID care. Rapid and accurate diagnosis of infection is critical to ensure appropriate antimicrobial therapy initiation and optimal subsequent management. In addition, appropriate diagnostic testing often identifies infecting pathogens and allows clinicians to optimize and narrow antimicrobial therapy. However, when diagnostic tests (eg, standard bacterial cultures or pathogen-specific molecular tests) are used inappropriately and identify an organism(s) that represents colonization or contamination, an infection may be inadvertently diagnosed. Patients that receive a diagnosis of an infection when an infection is not present are often treated with unnecessary antibiotics and have a delay in identifying the correct diagnosis that is causing their symptoms.16
In addition, some of the nationally reported healthcareassociated infections (HAIs) are identified entirely by a laboratory test or culture. Inappropriate testing, resulting in over-diagnosis of HAIs, can therefore increase a hospital’s publicly reported infection rate with resultant downstream consequences.17
TABLE 45-2 Examples of Diagnostic Stewardship Interventions That Can Be Led by Antimicrobial Stewardship Programs
Why a diagnostic stewardship intervention is needed?
Possible antibiotic stewardship program intervention
Urine cultures are commonly performed and often detect asymptomatic bacteriuria, which results in inappropriate antibiotic therapy
While performing prospective audit and feedback, identify patients with urine cultures without symptoms referable to the urinary tract and ensure they do not receive antibiotics
Educational campaign on appropriate testing18
Use the electronic health record to allow the option to order tests if results of initial tests are positive (eg, “urine culture if urine WBC > 10”)
Decreased antibiotic use
Decreased catheterassociated UTI detection rate
Decreased length of stay19
Clostridioides difficile stool tests
Diarrhea is a common symptom in hospitalized patients. Many patients are colonized with C difficile. Overtesting patients for C difficile leads to inappropriate diagnosis and treatment with further disruption of the gastrointestinal microbiome
Educational campaign on appropriate testing
Electronic health record (EHR) alerts to discourage C difficile testing when laxatives were recently received20
Microbiology laboratory interventions to reject samples of formed stool
Decreased treatment of patients with C difficile colonization.
Decreased healthcareassociated C difficile cases
Molecular syndromic respiratory panels
Multiplex PCR-based respiratory pathogen panels often contain over 10 targets. These panels are often costly and detect respiratory viruses that have no treatment available. Large panels have not been shown to improve outcomes.21 Pathogenspecific respiratory viral tests are available (eg, influenza) at a fraction of the cost and provide actionable data
Educational campaign on appropriate testing
EHR-based tools to discourage testing and promote pathogen-specific tests
Decreased cost for the patient and healthcare system
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