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Antimicrobial Stewardship

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Strategy ÎComputerized physician order entry further expands the potential for intervening at the time of prescribing. > Examples of tools are stop-order reminders and/or flags, order sets containing prophylaxis and treatment recommendations, assistance with dosing, information about formulary availability, and approval criteria for restricted antibiotics. ÎMany commercially available clinical decision support systems integrate electronic medical records and can facilitate both back-end and front-end approaches to providing real-time, patient-specific recommendations, although they cannot replace clinical judgment. Specific Antimicrobial Issues Restriction and/or preauthorization ÎFormulary based restriction: Agents that are entirely unavailable ÎCriteria-based restriction: Agents that are available for only certain indications ÎPreauthorization-based restriction: Agents that are available only after approval by some authority Intravenous-to-oral switch ÎAntimicrobial intravenous-to-oral switch can achieve substantial economic benefits. ÎProgram staff should consider which drugs to target, criteria for switching, and how the switch is performed. ÎThird-party payer criteria for inpatient status may not be affected by intravenous-to-oral switching. De-escalation or streamlining ÎDe-escalation or streamlining is a subclass of auditing and feedback that focuses on changing from initial broad-spectrum (often combination) empiric therapy to a narrower-spectrum (often monotherapy) agent when culture identification and susceptibility results become available. ÎIts role in limiting use of broad-spectrum antimicrobials can be fraught with complications. ÎSuccessful strategies must offer clear, predefined criteria for narrowing or discontinuing antimicrobials, while allowing for clinical judgment. 2

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