New Practitioners Forum

New Practitioners Forum A new practitioner’s guide to antimicrobial stewardship


t is commonly quoted that up to 50% of antimicrobial use is inappropriate.1 Notably, antimicrobial use is the principal driver of resistance development, frequently causes adverse effects, and is associated with Clostridium difficile infection (CDI). At the same time, the approval of new antimicrobial agents is precipitously decreasing.2 Given the frequent misuse of antimicrobials, the increasing rates of resistance, and the dearth of new agents, it is essential to ensure that antimicrobials are appropriately utilized. The need for antimicrobial stewardship has been recently highlighted at the state and national levels. California state bill 739, which was approved in 2008, required that acute care hospitals implement qualityassurance programs to ensure the judicious use of antimicrobials.3 In October 2011, after collaborating with the Centers for Disease Control and Prevention, the Centers for Medicare and Medicaid Services released new draft worksheets for accreditation by the Joint Commission that include new items to assess how each health care facility is promoting antimicrobial stewardship.4 Pharmacists play an integral role in antimicrobial stewardship and education due to their drug knowledge and ability to influence antimicrobial use.5 Most commonly, new pharmacy practitioners or pharmacists previously not involved in stewardship are spearheading these

efforts. For a new antimicrobial stewardship pharmacist, there is often pressure to quickly make large changes to validate the position or program and show a return on investment. Taking time to first survey the hospital setting and any existing antimicrobial stewardship program (ASP) will serve as valuable groundwork to prevent early missteps. Taking an inventory. To begin, examine the current antimicrobial stewardship team (if one exists). The Infectious Diseases Society of America–Society of Healthcare Epidemiology of America

guideline for developing ASPs identifies an infectious diseases (ID)-trained pharmacist and physician as the core members of the team.1 If an ID physician is not available, a physician without ID training may be willing to participate. Ideally the physician would have excellent teamwork skills and have influence at the administrative level.

The New Practitioners Forum column features articles that address the special professional needs of pharmacists early in their careers as they transition from students to practitioners. Authors include new practitioners or others with expertise in a topic of interest to new practitioners. AJHP readers are invited to submit topics or articles for this column to the New Practitioners Forum, c/o Jill Haug, 7272 Wisconsin Avenue, Bethesda, MD 20814 (301-664-8821 or [email protected]).


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Because an ASP cannot be successful without the support of the senior hospital leadership, the administration’s understanding of the program’s purpose, objectives, and goals is imperative when justifying a program or managing potential medical staff issues. Collaborations with individuals from the microbiology, information technology, infection control, and epidemiology departments are also helpful.1 Highlighting the rationale and vision for the ASP while demonstrating its benefits in these areas will allow the new practitioner to quickly develop partnerships. For example, beneficial collaborations with the microbiology laboratory staff can include the development of antibiograms, discussions on optimal formulary management and antibiotic susceptibility testing and reporting, and planning on how to practically implement changes recommended by the Clinical and Laboratory Standards Institute.5 If a microbiologist is not available at the institution, the pharmacist can coordinate with the department manager or other microbiologists in the area. Health information management (HIM) is indispensable in modern health systems for identification of stewardship opportunities as well as for generating metrics for assessing the performance of the ASP. It may take months to design and develop these reports, so starting early with the HIM department and data analysts is vital. Identifying opportunities and barriers. Many hospitals share similar ASP goals, but every facility has its own unique challenges and must design specific solutions—whether they are related to inappropriate prescribing or antimicrobial resistance. To elucidate the unmet needs, it can be useful to perform a gap analysis in collaboration with pharmaContinued on page 2182

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cists, administrators, and physicians in order to gather their ideas on improvements (and institutional strengths) as well as their perceptions on barriers to progress. Questions to consider include the following: Is there a misconception or attitude about the ASP among a specific group of prescribers? Is there a lack of coordination of implementation? Do initiatives tend to ultimately fail due to an absence of monitoring and accountability? Without a clear support structure, implementation accountabilities can fall to the new practitioner. Delegating responsibilities is important for maintaining an efficient ASP, as is including other pharmacists in the program. It is wise to seek out advice from the pharmacy leadership on managing difficult personalities or variances from expectations. The role of a stewardship pharmacist should focus on educating and empowering pharmacists—not on remediation of job performance (unless such duties are explicitly assigned). Creating solutions and effecting change. After assessing the opportunities and obstacles, it is time to develop the first project. With many potential opportunities to improve antimicrobial use, it can be difficult to know where to start. Obtaining antimicrobial-use data over time, in combination with tracking the institution’s antibiogram data, can aid in identifying potential projects. Another approach is to target high-cost or high-risk medications that are frequently misused, as determined by a medication-use evaluation. If the ASP is relatively new, it may be most productive to identify simple interventions that have a high impact. There are several well-established strategies for accomplishing antimicrobial stewardship, with significant evidence published in the literature. Substantial financial savings and improved patient care can be achieved by the introduction of i.v.-to-oral conversion policies, therapeutic substitutions, dose optimization (including extended-infusion b-lactams), and formulary restrictions.6-9 The pharmacist should be careful to account for facility-specific differences


in clinical problems and administrative structures. For example, if specialists or intensivists are not diligent in resource utilization, policies that restrict antimicrobials by specialty may have little effect; an extended-infusion b-lactam dosing scheme could be detrimental to patient care if nursing resources are not adequate to ensure that patients receive extended infusions. In established programs, it is necessary to continue previous projects while identifying new areas of opportunity— and to be realistic with initial expectations: Small steps are more manageable and palatable. Compromise is key, and antibiotic-use recommendations can always be refined in the future. By carefully examining the local antimicrobial prescribing culture, opportunities, and barriers, the ASP will be more efficient and successful because its leaders will know how and when to adapt a strategy to fit the institution’s needs. Engaging pharmacists. While antimicrobial stewardship duties may be expressly listed only in the ID pharmacist’s job description, the involvement of the entire pharmacy staff is crucial to a successful ASP. Every pharmacist can participate in antimicrobial stewardship activities. Providing continuous support and education will give the pharmacists knowledge and confidence when identifying and making recommendations to the medical team. ASP leaders should provide feedback to the pharmacy staff that highlights their interventions or the effects of their efforts. For example, if the prescribing of a frequently inappropriately used agent has decreased as a result of new guidelines and education, data documenting such improvements should be provided to the pharmacy staff to illustrate the positive effects of their efforts. Empowering pharmacists to assist with education of medical staff and to guide antimicrobial decisions is largely dependent on the institution’s practice model. There may be significant variance between institutions on how closely antibiotic therapy is being evaluated by pharmacists. The available pharmacy staff resources and the level of care provided can differ depending on the setting (e.g., a community hospital versus an

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academic medical center). For example, the communication between the clinical pharmacist and the care team can present a significant hurdle for many community hospitals. Making a recommendation on rounds is less disruptive and timeconsuming than calling an office to have the prescriber paged. Therefore, program implementation must be tailored to each institution. Measuring outcomes. Given that the principal objective of an ASP is “to optimize clinical outcomes while minimizing unintended consequences of antimicrobial use,” measurement of the ASP’s impact should ideally focus on clinical outcomes, adverse effects, CDI rates, and rates of resistant pathogens.1 Furthermore, measuring antimicrobial usage (e.g., days of therapy per 1000 patient-days) and cost (e.g., acquisition costs over time, corrected for inflation) is essential for identifying changes in prescribing and demonstrating the fiscal value of the ASP to the administration. Although detailed guidance in this area is outside the scope of this article, excellent review articles on outcome metrics for antimicrobial stewardship initiatives have been published.10,11 When starting an ASP, early identification of outcome metrics is essential to justify the program to hospital leadership. It is imperative that pharmacy and medical executives understand the ASP, what will be measured, and how the ASP will be justified from both a quality-ofcare and a cost standpoint. Decreased misuse of high-cost antimicrobials with the implementation of criteria-based restrictions or guidelines is a compelling metric for justifying the cost of a program early in its development. If entering an established ASP, the pharmacist should assess what metrics are already being reported and how they are obtained, as well as the expectations of pharmacy and medical leadership with regard to outcomes reporting. This is also an opportunity to identify new outcome metrics or refine those already in place. Outcome metrics can also relate to specific planned process improvements. For instance, for evaluating the time it takes from initial antimicrobial ordering to drug administration in the intensive care unit, monitoring and reporting im-

New Practitioners Forum

provements in the average time to drug administration are essential. Or, if fluoroquinolones are being used empirically for gram-negative infections at a location with high fluoroquinolone resistance rates, one can monitor adherence to local guidelines that exclude fluoroquinolones and the related changes in use over time. Although not direct measures of patient outcomes, process measures are indicators of improved care and may be less subjective than outcome measures such as clinical cure. Occasionally, a manual chart review of the appropriateness of antimicrobial therapy is necessary; however, this can be time-consuming and should not be used as a standard ASP metric. Reporting of performance is important but can overwhelm program resources if an efficient system is not established. Therefore, once potential outcome metrics are identified, an inventory should be taken of available monitoring resources (e.g., means of tracking drug usage, drug acquisition cost, and CDI rates). Establishing partnerships with infection-control, hospital epidemiology, data analysis, and information technology personnel within the organization will facilitate this inventory process; when possible, enlisting the aid of pharmacy interns and residents can also facilitate data collection. Collaboration, mentorship, and training. A primary distinction between a pharmacy student or resident and a new practitioner is the learning environment. As a student or resident, there is a strong framework of learning, guidance, and mentorship. For many new practitioners, this structured learning environment is significantly diminished. For new practitioners involved in antimicrobial stewardship, excellent training is available, including programs from Making a Difference in Infectious Diseases Pharmacotherapy ( and the Society of Infectious Diseases Pharmacists ( In addition, new practitioners should continue to maintain their relationships with mentors and seek out new collaborators at the local, regional, and national levels. Establishing local or regional dinners with journal clubs or focused stew-

ardship discussions can be terrific venues for developing these relationships and working together to solve problems. Attending national meetings and presenting data from one’s own ASP allow for additional networking and collaboration opportunities. While cultivating their own antimicrobial stewardship expertise, new practitioners will serve regularly as mentors for pharmacy students and peers at the home institution by virtue of their specialized knowledge and leadership roles. These mentorship skills can be further developed through working frequently with peers and pharmacy students as well as by seeking out specific programming focused on mentorship–leadership development (e.g., programs offered at the annual ASHP Conference for Leaders in Health-System Pharmacy). Summary and closing notes. Antimicrobial stewardship is a systematic process whose aim is to optimize antimicrobial selection, dosage, route of administration, and duration of therapy to improve patient outcomes, with the secondary goals of decreasing resistance and reducing costs. Inpatient facilities across the United States are increasingly implementing ASPs, and new pharmacy practitioners are commonly stepping into ASP leadership roles. It is challenging and exciting for new practitioners to be a driving force in improving antimicrobial usage. To be effective in this important field, the new practitioner must take a methodical and measured approach in the implementation and maintenance of an ASP. 1. Dellit TH, Owens RC, McGowan JE et al. Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clin Infect Dis. 2007; 44:159-77. 2. Boucher HW, Talbot GH, Bradley JS et al. Bad bugs, no drugs: no ESKAPE! An update from the Infectious Diseases Society of America. Clin Infect Dis. 2009; 48:1-12. 3. California Department of Public Health. The California antimicrobial stewardship program initiative. programs/hai/Pages/Antimicrobial StewardshipProgramInitiative.aspx (accessed 2013 Jan 21). 4. Centers for Medicare and Medicaid Services. Survey & certification focus on patient safety and quality—draft surveyor

worksheets. Provider-Enrollment-and-Certification/ SurveyCertificationGenInfo/downloads/ SCLetter12_01.pdf (accessed 2013 Sep 14). 5. American Society of Health-System Pharmacists. ASHP statement on the pharmacist’s role in antimicrobial stewardship and infection prevention and control. Am J Health-Syst Pharm. 2010; 67:575-7. 6. Goff DA, Bauer KA, Reed EE et al. Is the “low-hanging fruit” worth picking for antimicrobial stewardship programs? Clin Infect Dis. 2012; 55:587-92. 7. Kaufman SE, Donnell RW, Hickey WS. Rationale and evidence for extended infusion piperacillin–tazobactam. Am J Health-Syst Pharm. 2011; 68:1521-6. 8. Kuti JL, Le TN, Nightingale CH et al. Pharmacoeconomics of a pharmacistmanaged program for automatically converting levofloxacin route from i.v. to oral. Am J Health-Syst Pharm. 2002; 59:2209-15. 9. Gross R, Morgan AS, Kinky DE et al. Impact of a hospital-based antimicrobial management program on clinical and economic outcomes. Clin Infect Dis. 2001; 33:289-95. 10. Khadem TM, Dodds AE, Wrobel MJ et al. Antimicrobial stewardship: a matter of process or outcome? Pharmacotherapy. 2012; 32:688-706. 11. McGowan JE. Antimicrobial stewardship— the state of the art in 2011: focus on outcome and methods. Infect Control Hosp Epidemiol. 2012; 33:331-7.

Ashley M. Wilde, Pharm.D., Clinical Pharmacy Specialist—Infectious Diseases Norton Healthcare 200 East Chestnut Street Louisville, KY 40202 [email protected] Alan E. Gross, Pharm.D., BCPS, Infectious Diseases Pharmacist University of Illinois Hospital and Health Sciences System Chicago, IL Clinical Assistant Professor of Pharmacy Practice University of Illinois at Chicago College of Pharmacy

The assistance of Marc H. Scheetz, Pharm.D., BCPS-AQID, in review of the manuscript is acknowledged. The authors have declared no potential conflicts of interest. DOI 10.2146/ajhp130032

Am J Health-Syst Pharm—Vol 70 Dec 15, 2013


A new practitioner's guide to antimicrobial stewardship.

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