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Antibiotic Stewardship Programs in the Hospital Setting: Guidance from the Centers for Disease Control and Prevention



ASPs should implement policies supporting optimal antibiotic use and avoid addressing too many interventions simultaneously. Interventions should be prioritized based on the hospital’s needs and availability of resources / content expertise.
CDC’s guidance breaks down actionable interventions into three types: broad, pharmacy-driven, and infection/syndrome specific interventions. Examples of broad interventions include antibiotic “time outs”, prior authorization, and prospective audit and feedback. Antibiotic “time outs” prompt a reassessment of continued need and choice of initial empiric antibiotics, usually when more diagnostic information is available. Some facilities may choose interventions focusing on prior authorization strategies, where antibiotic restriction is done to ensure use is reviewed with an antibiotic expert before therapy is initiated. Alternatively, prospective audit and feedback may be utilized by other ASPs, allowing for direct interaction with the provider after initial ordering and dispensing of the agent is complete.
ASPs should implement policies supporting optimal antibiotic use and avoid addressing too many interventions simultaneously.
Pharmacy-driven interventions focus directly on interventions made by pharmacy staff and come in various forms. Automatic changes from intravenous to oral therapy can be performed in appropriate situations and for antibiotics with good absorption in order to improve patient safety and reduce the need for intravenous access. Dose optimization, including modifications based on therapeutic drug monitoring and organ function, allows for adjustments in antibiotics based on pharmacokinetic and pharmacodynamics considerations of the drug. Pharmacists can respond to alerts for situations where duplicate therapy might be unnecessary, such as simultaneous use of multiple agents with overlapping spectra. ASPs may implement time-sensitive automatic stop orders for specified scenarios, especially for surgical prophylaxis. Finally, detection and prevention of antibiotic-related drug-drug interactions may be considered, including interactions between orally administered fluoroquinolones and certain vitamins.
Infection and syndrome specific interventions are intended to improve prescribing for specific syndromes; however, these should not interfere with prompt and effective treatment for severe infections or sepsis. Some examples include community-acquired pneumonia, urinary tract infections, skin and soft tissue infections, empiric coverage of methicillin-resistant Staphylococcus aureus (MRSA), and CDI. In these situations, optimizing the agent of use, dosing, and duration of therapy are imperative. Local resistance patterns and national guidelines will assist ASPs to implement these recommendations at their institution. When considering CDI, these infections can be a direct result of antibiotic use and should be a large focus for ASPs. Reviewing antibiotics in patients with new diagnoses of CDI can identify opportunities to discontinue unnecessary antibiotics. 

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