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Antimicrobial Stewardship

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Table 1. Antimicrobial Stewardship Strategies with Associated Barriers and Solutions Strategy Auditing and feedback Barriers to Effective Implementation Problems in identifying patients who are receiving suboptimal therapy Difficulty communicating recommendations to providers Lack of clarity in appropriate methods for providing feedback Medicolegal concerns about providing feedback in the medical record Restriction and/or preauthorization Perceived challenge to physician autonomy Integration of restriction policies into workflow Prescriber education Lack of knowledge about the role of stewardship programs Guideline implementation Application of information technology Intravenous-to-oral switch De-escalation or streamlining Poor knowledge of, and adherence to, guidelines for antimicrobial use Considerable investment of financial and human resources Identification of eligible patients Unwillingness of providers to de-escalate or streamline Dosage optimization Nursing concerns regarding administration and drug incompatibility Potential Solutions Use rules-based computer systems that combine pharmacy and microbiologic data to flag patients of interest. Manually review antimicrobial order sheets. Review microbiologic data to identify targeted organisms. Approve policy delineating appropriate means of communicating recommendations. Create nonpermanent forms for written communication in the medical record. Time communication for greatest likelihood of impact (eg, before rounds). Hold intermittent, regularly scheduled antibiotic rounds between the stewardship team and staff from services that heavily use antimicrobials. Have an approved policy by the medical executive committee. Grant time-restricted approvals (eg, for 24-72 hrs) to balance physicians' and stewardship concern. Regularly review the use of restricted agents to evaluate their continued restriction. Use computerized physician order-entry systems to give restriction notifications automatically. Use dedicated pagers for restricted agents to minimize delays in authorization. Establish clear procedures for authorization a┼┐ter hours. Hold antimicrobial stewardship grand rounds to explain the program and provide hospital-specific data. Disseminate information in printed handbooks, integrate it in order sets, and provide easy access on Internet or intranet. Involve opinion leaders from multiple specialties in developing guidelines. Emphasize its importance in patient safety and the potential to avoid substantial costs. On a daily basis, review patients receiving intravenous forms of highly bioavailable antimicrobials. Develop criteria to help clinicians determine candidacy for switch (eg, body temperature, white blood cell count). Refer to studies that demonstrated safety of de-escalation or streamlining when resistant organisms were not identified. Create protocols for administration and list compatible drugs. Consider extended infusion instead of continuous infusion. 3

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