- Providing at least yearly antibiograms (if possible twice a year). Antibiogram reporting should be location specific (e.g., ICU, general wards, or pediatric areas). [MG monthly would be better in acute outbreaks]
- Incorporate rapid diagnostics such as multiplex PCR and Matrix Assisted Laser desorption/ionization –time of flight (MALDI-TOF).
- Rapid diagnostics have been demonstrated to decrease the time to appropriate antibiotics and decrease the time on unnecessary antimicrobial therapy.
- Incorporate Pro-calcitonin level measurement in the laboratory to aid in antibiotic initiation and discontinuation.
- During bacterial infection, Pro-calcitonin is produced in large quantities by body tissues. Strong evidence supports its use in antibiotic management of infections, particularly, pneumonia or other lower respiratory tract infections, and has been demonstrated to significantly decrease unnecessary antibiotic use and shorten duration of therapy. Pro-calcitonin levels must be correlated to laboratory specific metrics for best results.
- Automatic testing and reporting of tigecycline and colistin for Carbapenem Resistant Enterobacteriaceae isolates.
- As carbapenem resistance is increasingly reported, it is critical that alternative agent susceptibilities be made available. These alternative agents include tigecycline and colistin. While breakpoints for susceptibility are not available by CLSI, FDA breakpoints are available and should be used for interpretation.
- Reporting of minocycline susceptibility for Acinetobacter isolates.
- Minocycline susceptibility remains high in most institutions against multi-drug resistant Acinetobacter spp, hence this should be taken advantage of as its resistance patterns allow.
- Selective reporting of susceptibilities of antimicrobials.
- Selective reporting is a process of withholding susceptibility results from selected categories of antibiotics that may have deleterious effects on the hospital antibiogram/resistance rates, or financial cost that do not have a therapeutic advantage over other commonly used antimicrobial agents. For example, if an E. coli strain is isolated from a bloodstream infection and is not susceptible to a 1st generation cephalosporin but is susceptible to cefotaxime, other broader agents such as cefepime, meropenem, or ceftaroline can be withheld and only made available upon the request of the physician for good cause. Certain extended broad spectrum lactamase [EBSL] resistance bacteria and particularly virulent bacteria (E. coli K1) may merit special consideration.
Leadership Plan
Commitment from the hospital leadership is required for the successful implementation and progress of any clinical program, including the ASPs. Commitment and support of ASPs should not only come from the ASP committee or infectious diseases physicians, but also from the senior administration. Formal statements made at the administrative level in support of the program implementation and progression should be clear, in this way practitioners at the hospital will know and understand the importance of the ASP’s presence and goals. Some approaches that hospital/facility leadership should include in support of the ASP are:\cite{50},\cite{Dellit_2007}
- Financial support
- Formal statements supporting the ASP and optimal use of antimicrobials within the hospital
- Protected/acknowledged time for personnel from various departments to participate in the ASP.
- Provide training and support to personnel
- Provision of necessary infrastructure for tracking and measuring antimicrobial use and outcomes.
Practice Plan
Each hospital should create a multidisciplinary team that includes an ID physician, ID-trained or clinical pharmacist, microbiologist, infection control, and information technologists.\cite{50} Depending on the size, type, and resources available to the hospital different strategies can be employed.
In a large academic hospital it may be possible to form an antimicrobial stewardship committee and implement either a restrictive ASP or prospective audit with feedback. In a restrictive program, select antimicrobials are placed on formulary restriction for use in only select indications. Dispensing of a restricted agent would require approval by designated personnel, usually an ID physician, ID fellow, or clinical pharmacist. The advantages of this program are:
(a) the direct oversight in the use of targeted antimicrobials,
(b) reduction of pathogen resistance within the hospital and communities,
(c) reduced hospital LOS, and
(d) reduced risks of antimicrobial-related side effects and drug-drug interactions.
The disadvantages may include:
(a) the requirement of personnel availability around-the-clock,
(b) physicians may perceive this as a loss of autonomy, and
(c) review of appropriateness only occurs with targeted/restricted agent, but not for non-restricted agents which can also lead to problems.\cite{Goff_2012},\cite{Dellit_2007}
An alternative to the restrictive program is a prospective audit with feedback program. In this program, a retrospective (hours to days) review of antimicrobial orders takes place for targeted and in some institutions non -targeted antimicrobials for appropriateness. It is also common to find programs that use a hybrid approach in which audit and feedback are employed along with a restricted formulary. Advantages of the prospective audit with feedback are the avoidance of loss of autonomy and the opportunity to educate individuals rather than only restrict utilization. A disadvantage is compliance is often voluntary.\cite{Dellit_2007}
Implementation of the above two strategies require personnel dedicated to the ASP. In most academic and medium-to-large community hospitals, formation of an ASP with either of these strategies is achievable. On the other hand, in smaller hospitals where dedicated personnel may not be available, only some of the pharmacy driven interventions mentioned previously can be implemented, as they require less resources and effort. These have been referred to as “low hanging fruit” interventions as they are the simplest to implement and yet have been shown to have a significant positive impact.\cite{Goff_2012} Such interventions include intravenous-to-oral conversions, therapeutic substitutions, batching of intravenous antimicrobials, monitoring and discontinuing preoperative antibiotic prophylaxis.
The Centers for Disease Control and Prevention has provided recommendations on core elements that should be implemented for hospital ASPs.5 These include:
- Commitment from institutional leadership (technology, personnel, finance)
- Accountability of ASP chair or co-chairs
- A clinician with drug expertise in antimicrobials [e.g., clinical pharmacist (Infectious Disease trained)]
- Actionable program components (e.g., prospective audit, automatic discontinuation orders)
- Monitoring of microbial resistance and infection patterns
- Reporting of and education about ASP findings to hospital staff (physicians, nurses, pharmacists, etc.)
Technology Plan
To be successful in implementing this Actionable Patient Safety Solution will rely on implanting a technology plan using the following systems. Other specific strategies will be developed or become apparent as the above are implemented. This action plan will include careful observation of the consequences of each new strategy, which will in turn lead to additional novel ideas for further improvement in medication administration safety.
Suggested practices and technologies are limited to those proven to show benefit or are the only known technologies with a particular capability. As other options may exist, please send information on any additional technologies, along with appropriate evidence, to info@patientsafetymovement.org.