Are you starting an antimicrobial stewardship program (ASP) and perhaps unsure of which initiatives to tackle first? Consider beginning with initiatives that are easiest to achieve…the “low-hanging fruit." What is considered low-hanging fruit in your practice may depend on several factors, such as organizational priorities around infection management and the comfort level and knowledge base of your staff related to antimicrobial stewardship activities.
Here are some examples of initiatives to consider for your initial ASP efforts:
- IV-to-Oral Conversions
- Intravenous to oral medication conversions are bread and butter pharmacy activities that have been shown to improve quality and reduce costs. Developing a pharmacy protocol or guideline targeting antimicrobials would be an ideal first start for your ASP initiative. Converting antimicrobials to oral formulations generally requires more consideration that non-antimicrobial medications such as the patient’s infection status (eg, WBC, temperature). Policies can be developed with your infectious disease physicians and approved by the P&T Committee and these can include the authority for pharmacists to automatically convert antimicrobials to the oral form per protocol.
- Dose Optimization: Renal Dosing
- Similar to IV-to-oral conversions, renal dosing is a common service provided by pharmacists and targeting antimicrobials is known to reduce therapeutic failures and adverse events. The development of a protocol or guideline is the key to implementing this initiative. The guideline should give clear direction to the pharmacist as to which medications should/can be adjusted, along with the appropriate adjustments based on the level of renal function and other patient-related considerations as well as the accompanying evidence to support the recommendation. Similar to the IV-to-oral conversation policy, renal dosing activities by pharmacists may evolve to include authority for automatic dose adjustments that improve time to appropriate care.
- Formulary Restrictions
- Formulary restrictions target the first step in the antimicrobial use process – selection – and have proven to be highly effective approach for ASPs. There are several approaches to formulary restrictions with the more common methods requiring pre-authorization by an ID physician or pharmacist. Typically, approval of specific antimicrobial request will require the prescriber to meet pre-approved appropriate use criteria. While effective and perhaps a good starting place, use restrictions will require careful consideration about the approval process to ensure initial treatment is not inappropriately delayed. As an alternative to the restricted antimicrobial approach, appropriate use criteria can be determined during the formulary review process that can also be used as guidelines for antimicrobial use that assist prescribers in their antimicrobial selection.
- De-escalation 101
- Ensuring initial and/or empiric therapy is appropriate based on microbiology results and other clinical information is a critical component of any ASP. The majority of de-escalation opportunities involve working through a detailed clinical checklist to determine the appropriate antimicrobial selection. Some de-escalation opportunities, however, are straight forward and can be supported with a multitude of evidence-based literature. For example, when a culture comes back as methicillin-sensitive Staphylococcus aureus and the patient is being treated with vancomycin, consider switching to a more targeted antimicrobial such as oxacillin. Targeting these opportunities would be a good start for any ASP.
The initiatives listed here are designed to help achieve the core goal of any antimicrobial stewardship program, that is, to optimize clinical outcomes while minimizing unintended consequences of antimicrobial use. Once your team has decided upon which low-hanging fruit ASP initiatives to target, the next step is to launch these initiatives in your practice site. Health information technology, such as electronic surveillance software, can greatly assist with the effective and efficient provision of these services and support a phased approach to rolling out these initiatives based on your practice sites unique needs and capabiliites.
What are some of the “low-hanging fruit” ASP initiatives at your hospital?