Antimicrobial Stewardship JONATHAN PERDUE, PHARMD PGY1 PHARMACY - - PDF document

9/21/2017 1

Antimicrobial Stewardship

JONATHAN PERDUE, PHARMD PGY1 PHARMACY RESIDENT

• ST. CLAIRE REGIONAL MEDICAL CENTER

09/23/2017

1

Disclosure

This speaker has no actual or potential conflicts of interest related to this presentation

2

Objectives

• Define antimicrobial stewardship
• Describe different antimicrobial stewardship initiatives
• Discuss literature demonstrating the impact of different

antimicrobial stewardship initiatives

3

9/21/2017 2 What is Antimicrobial Stewardship?

• Antimicrobial stewardship is defined in a consensus statement by

the Society for Healthcare Epidemiology of American (SHEA), Infectious Diseases Society of America (IDSA), and Pediatric Infectious Diseases Society (PIDS) as:

• “Coordinated interventions designed to improve and measure the

appropriate use of antimicrobial agents by promoting the selection of the optimal antimicrobial drug regimen including dosing, duration of therapy, and route of administration.”

Fishman N. Infect Control Hosp Epidemiol. 2012; 33: 322–7. 4

Why is Antimicrobial Stewardship Important?

• Between 20% and 50% of all antibiotics prescribed are

inappropriate

• Antibiotic resistance is increasing
• Few new antibiotics are being developed
• Nearly 20 antibiotics were introduced from 1980‐1984
• About 10 were introduced in the past decade
• Joint Commission Standard
• CDC. Antibiotic Resistant Threats in the United States, 2013.

The Joint Commission. Jt Comm Perspect. July 2016; 36(7): 1, 3‐4, 8. 5

Antibiotic Prescriptions by State

• CDC. Antibiotic Resistant Threats in the United States, 2013.

529‐656 689‐774 780‐836 843‐896 899‐972 996‐1237

6

9/21/2017 3 The Basis of Antimicrobial Stewardship

• Statement by Sir Alexander Fleming to the New York Times on June

26, 1945:

• “…the microbes are educated to resist penicillin and a host of

penicillin‐fast organisms is bred out…In such cases the thoughtless person playing with penicillin is morally responsible for the death

• f the man who finally succumbs to infection with the penicillin‐

resistant organism. I hope this evil can be averted.”

Fishman N. Infect Control Hosp Epidemiol. 2012; 33: 322–7. 7

Antibiotic Timeline

1943 ‐ PCN Enters Mass Production 2009 – PDR Enterobacteriaceae 1940 ‐ PCN resistant S. aureus 1960 ‐ Methicillin Introduced 1972 – Vancomycin Introduced 1962 ‐ MRSA 1988 ‐ VRE 1965 – PCN resistant S. pneumoniae 1967 – Gentamicin Introduced 1979 – Gentamicin resistant Enterococcus 1985 – Ceftazidime Introduced 1987 – Ceftazidime resistant Enterobacteriaceae 1996 – Levofloxacin Introduced 1996 – Levofloxacin resistant S. pneumoniae 2002 ‐ VRSA

PCN = Penicillin; MRSA = Methicillin Resistant Staphylococcus aureus; VRSA = Vancomycin Resistant Staphylococcus aureus; VRE = Vancomycin resistant Enterococcus; PDR = Pandrug‐resistant

• CDC. Antibiotic Resistant Threats in the United States, 2013.

8

Colistin Resistance in the US

• On May 31, 2016 the Centers for Disease Control and Prevention

(CDC) issued a press release stating that the mcr‐1 gene was identified for the first time in the US in E. coli

• Codes for resistance to colistin, which is often the last line of

therapy for multidrug‐resistant (MDR) Gram negative infections

• The gene is encoded on a plasmid, meaning it can be transferred to
• ther bacteria (including other species)
• CDC. Discovery of first mcr‐1 gene in E. coli bacteria found in a human in United States.

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9/21/2017 4

Que Questio ion 1

What percentage of antibiotic prescriptions are inappropriate?

• A. 5‐10%
• B. 10‐30%
• C. 20‐50%
• D. 40‐60%
• E. 50‐75%

10

What are the Primary Goals of an Antimicrobial Stewardship Program (ASP)?

Improve patient

• utcomes

1

Reduce rates of antimicrobial resistance

2

Reduce rates of Clostridium difficile infection (CDI)

3

Reduce costs

4

• CDC. Core Elements of Hospital Antibiotic Stewardship Programs.

Barlam TF, Cosgrove SE, Abbo LM, et al. Clin Infect Dis. 2016; 62: 51‐77 11

Preauthorization

• A strategy in which prescribers are required to obtain approval in
• rder to prescribe certain antibiotics
• Results in significant reduction in usage of restricted antibiotics
• Reduces costs associated with restricted antibiotics
• Decreased antimicrobial resistance
• No adverse effects on patient outcomes
• CDC. Core Elements of Hospital Antibiotic Stewardship Programs.

Barlam TF, Cosgrove SE, Abbo LM, et al. Clin Infect Dis. May 2016; 62(10): e51‐e77. 12

9/21/2017 5 Preauthorization Advantages

• Reduces initiation of unnecessary/ inappropriate antimicrobials
• Optimizes empiric choices and influences downstream use
• Prompts review of clinical data/prior cultures at the time of initiation of

therapy

• Decreases antimicrobial costs, including those due to high‐cost agents
• Provides mechanism for rapid response to antimicrobial shortages
• Direct control over antimicrobial use
• CDC. Core Elements of Hospital Antibiotic Stewardship Programs.

Barlam TF, Cosgrove SE, Abbo LM, et al. Clin Infect Dis. May 2016; 62(10): e51‐e77. 13

Preauthorization Disadvantages

• Impacts use of restricted agents only
• Addresses empiric use to a much greater degree than downstream use
• Loss of prescriber autonomy
• May delay therapy
• Effectiveness depends on skill of approver
• Real‐time resource intensive
• Potential for manipulation of system (e.g., presenting request in a biased manner to gain

approval)

• May simply shift to other antibiotic agents and select for different antibiotic‐resistance

patterns

• CDC. Core Elements of Hospital Antibiotic Stewardship Programs.

Barlam TF, Cosgrove SE, Abbo LM, et al. Clin Infect Dis. May 2016; 62(10): e51‐e77. 14

Prospective Audit & Feedback (PAF)

• A strategy in which prescribing of antimicrobials is monitored and

assessed by a person or persons other than the prescribing team

• The prescribing team is given education and advice on how to best

tailor the antimicrobial regimen to the patient

• PAF has been shown to improve antimicrobial use, reduce

antimicrobial resistance, and reduce CDI rates

• No adverse effects on patient outcomes
• CDC. Core Elements of Hospital Antibiotic Stewardship Programs.

Barlam TF, Cosgrove SE, Abbo LM, et al. Clin Infect Dis. May 2016; 62(10): e51‐e77. 15

9/21/2017 6 Prospective Audit & Feedback (PAF) Advantages

• Can increase visibility of antimicrobial stewardship program and build collegial

relationships

• More clinical data available for recommendations, enhancing uptake by

prescribers

• Greater flexibility in timing of recommendations
• Can be done on less than daily basis if resources are limited
• Provides educational benefit to clinicians
• Prescriber autonomy maintained
• Can address de‐escalation of antimicrobials and duration of therapy
• CDC. Core Elements of Hospital Antibiotic Stewardship Programs.

Barlam TF, Cosgrove SE, Abbo LM, et al. Clin Infect Dis. May 2016; 62(10): e51‐e77. 16

Prospective Audit & Feedback (PAF) Disadvantages

• Compliance voluntary
• Typically labor‐intensive
• Success depends on delivery method of feedback to prescribers
• Prescribers may be reluctant to change therapy if patient is doing well
• Identification of interventions may require information technology support

and/or purchase of computerized surveillance systems

• May take longer to achieve reductions in targeted antimicrobial use
• CDC. Core Elements of Hospital Antibiotic Stewardship Programs.

Barlam TF, Cosgrove SE, Abbo LM, et al. Clin Infect Dis. May 2016; 62(10): e51‐e77. 17

Preauthorization vs. PAF

• A Cochrane review found that preauthorization and PAF had similar

effects on prescribing outcomes at 12 and 24 months

• Preauthorization was superior to PAF for prescribing outcomes at 1

month and for CDI at 6 months

• Mehta et al. found that when preauthorization was changed to

PAF, overall antibiotic use increased

• Preauthorization and PAF are not mutually exclusive
• A combination of both strategies can be effective
• CDC. Core Elements of Hospital Antibiotic Stewardship Programs.; Barlam TF, Cosgrove SE, Abbo LM, et al. Clin Infect Dis. May 2016; 62(10): e51‐e77.

Davey P, Brown E, Charani E, et al. Cochrane Database Syst Rev. 2013; 4:CD003543.; Mehta JM, Haynes K, Wileyto EP, et al. Infect Control Hosp Epidemiol. 2014; 35:1092–9. 18

9/21/2017 7

Que Questio ion 2

All of the following statements about preauthorization are TRUE EXCEPT:

• A. Reduces costs associated with restricted

antibiotics

• B. Decreases antimicrobial resistance
• C. Reduces prescriber autonomy
• D. Adversely affects patient outcomes
• E. Optimizes empiric antibiotic choices

19

Que Questio ion 3

All of the following statements about prospective audit & feedback (PAF) are TRUE EXCEPT:

• A. Results may take longer than preauthorization
• B. Does not adversely affect patient outcomes
• C. May be less popular with prescribers

compared to preauthorization

• D. Success may depend on the delivery method
• f feedback
• E. Reduces antimicrobial resistance

20

Que Questio ion 4

Preauthorization and prospective audit & feedback (PAF) are mutually exclusive.

True False

21

9/21/2017 8 Antibiotic “Time Outs”

• An antibiotic “time out” is a reassessment of an antibiotic regimen by the prescribing

team

• The CDC recommends an antibiotic “time out” 48 hours after initial antibiotics to

answer the following questions:

• Does this patient have an infection that will respond to antibiotics?
• If so, is the patient on the right antibiotic(s), dose, and route of administration?
• Can a more targeted antibiotic be used to treat the infection (de‐escalate)?
• How long should the patient receive the antibiotic(s)?
• Unlikely to be effective unless enforced prompting or reminders are in place
• CDC. Core Elements of Hospital Antibiotic Stewardship Programs.

Barlam TF, Cosgrove SE, Abbo LM, et al. Clin Infect Dis. May 2016; 62(10): e51‐e77. 22

Didactic Education

• Used alone, this is not an effective stewardship strategy and should be avoided
• Should complement other stewardship strategies to be most effective
• Should be multidisciplinary
• Physicians, pharmacists, PAs, APRNs, nursing staff, and residents
• Abbo et al. found 90% of 4th year medical students reported wanting more

education regarding appropriate antimicrobial use

• Mean knowledge scores for these students were low

Barlam TF, Cosgrove SE, Abbo LM, et al. Clin Infect Dis. May 2016; 62(10): e51‐e77. Abbo LM, Cosgrove SE, Pottinger PS, et al. Clin Infect Dis. 2013; 57:631–8. 23

Que Questio ion 5

Didactic education alone is an effective antimicrobial stewardship strategy.

True False

24

9/21/2017 9 Facility‐Specific Guidelines

• Clinical practice guidelines for common infectious diseases can result in improvements in

antimicrobial use

• Increased likelihood of adequate empiric therapy
• Use of narrower spectrum agents
• Earlier IV to PO switch
• Shorter treatment durations
• These improvements have demonstrated reductions in:
• Mortality
• Hospital length of stay (LOS)
• Adverse events
• Readmission rates
• Treatment costs

Barlam TF, Cosgrove SE, Abbo LM, et al. Clin Infect Dis. May 2016; 62(10): e51‐e77. 25

Facility‐Specific Guidelines

• The CDC recommends specific treatment plans for community

acquired pneumonia (CAP), urinary tract infections (UTIs), and skin and soft tissue infections (SSTIs)

• Enforcement of guidelines may be necessary for long‐term

adherence

• No adverse effects on patient outcomes

Barlam TF, Cosgrove SE, Abbo LM, et al. Clin Infect Dis. May 2016; 62(10): e51‐e77. 26

Que Questio ion 6

Facility‐specific guidelines have been shown to:

• A. Reduce mortality
• B. Reduce costs
• C. Reduce hospital LOS
• D. Reduce readmission rates
• E. All of the above

27

9/21/2017 10 Targeting Antibiotics with High CDI Risk

• Reducing CDI rates should be a priority for all ASPs
• The CDC considers CDI to be one of the highest priority bacterial health threats in the US
• ASPs have been successful in reducing CDI rates
• Valiquette et al. found that increasing infection control measures did not reduce CDI, but

implementation of ASPs that targeted high risk antibiotics did

• Reducing clindamycin use has been shown to reduce CDI rates and reduce overall costs due to

fewer CDI cases

• Other high risk antibiotics include fluoroquinolones, cephalosporins, monobactams, and

carbapenems

• CDC. Antibiotic Resistant Threats in the United States, 2013.; Barlam TF, Cosgrove SE, Abbo LM, et al. Clin Infect Dis. May 2016; 62(10): e51‐e77.

Brown KA, Khanafer N, Daneman K, Fisman DN. Antimicrob Agents Chemother. May 2013; 57(5): 2326‐2332.; Valiquette L, Cossette B, Garant MP, Diab H, Pepin J. Clin Infect Dis. 2007; 45(suppl 2):S112–21 28

CDI Risk by Antibiotic Class

Brown KA, Khanafer N, Daneman K, Fisman DN. Antimicrob Agents Chemother. May 2013; 57(5): 2326‐2332 29

Que Questio ion 7

The antibiotic associated with the highest risk of Clostridium difficile infection (CDI) is:

• A. Doxycycline
• B. Piperacillin/tazobactam
• C. Cefepime
• D. Levofloxacin
• E. Clindamycin

30

9/21/2017 11 Computerized Clinical Decision Support

• Provides prescribers with suggestions at the time of prescribing
• Has been shown to reduce:
• Mortality
• Hospital LOS
• Broad‐spectrum antimicrobial use
• Dosing errors
• Adverse events
• Costs
• May be particularly useful in combination with PAF to reduce time to intervention and

facilitate more interventions

Barlam TF, Cosgrove SE, Abbo LM, et al. Clin Infect Dis. May 2016; 62(10): e51‐e77. 31

Automatic IV to PO Switch

• Omidvari et al. showed that interventions aimed at increasing the use of oral

antibiotics are associated with reduced costs and hospital LOS

• May also reduce the need for outpatient parenteral antibiotic therapy
• Laing et al. found improvements in patient safety by reducing the need for IV

access

• ASPs may have a particularly important role in IV to PO transitions for drugs

that do not have an exact PO equivalent (e.g. piperacillin/tazobactam)

• No adverse effects on patient outcomes
• CDC. Core Elements of Hospital Antibiotic Stewardship Programs.; Barlam TF, Cosgrove SE, Abbo LM, et al. Clin Infect Dis. May 2016; 62(10): e51‐e77.

Omidvari K, de Boisblanc BP, Karam G, Nelson S, Haponik E, Summer W. J Antimicrob Chemother. 1998; 92:1032–9; Laing RB, Mackenzie AR, Shaw H, Gould IM, Douglas JG. J Antimicrob Chemother. 1998; 42:107–11. 32

Automatic Stop Dates

• Antimicrobial therapy should be for the shortest effective duration
• Hepburn et al. found no difference in outcomes in adults with uncomplicated

cellulitis with a 5 vs 10 day treatment course

• Guglielmo et al. found automatic stop orders reduced vancomycin use in the

absence of Gram‐positive infection, in febrile neutropenia, and overall

• Antibiotics for surgical prophylaxis are prime targets for automatic stop dates
• Care must be taken with automatic stop dates to ensure therapy is not

interrupted unnecessarily

• CDC. Core Elements of Hospital Antibiotic Stewardship Programs.; Barlam TF, Cosgrove SE, Abbo LM, et al. Clin Infect Dis. May 2016; 62(10): e51‐e77.

Guglielmo B, Dudas V, Maewal I, et al. Jt Comm Qual Patient Saf. 2005; 31:469–75.; Hepburn MJ, Dooley DP, Skidmore PJ, Ellis MW, Starnes WF, Hasewinkle WC. Arch Intern Med. 2004; 164:1669–74. 33

9/21/2017 12 Penicillin Allergy Testing

• As many as 90% of reported penicillin allergies may be false
• Penicillin allergy is reported in 10‐15% of hospitalized patients
• Patients who report penicillin allergies have increased:
• CDI rates
• MRSA rates
• VRE rates
• Hospital LOS
• Structured drug allergy assessments have been associated with:
• Increased guideline adherence
• Reduced hospital LOS
• Reduced costs

Penicillin Allergy Testing: AAAAI Advocacy Priority. American Academy of Allergy, Asthma, and Immunology Website. Barlam TF, Cosgrove SE, Abbo LM, et al. Clin Infect Dis. May 2016; 62(10): e51‐e77. 34

Que Questio ion 8

Approximately what percentage of penicillin allergies are false?

• A. 10%
• B. 50%
• C. 70%
• D. 90%
• E. 100%

35

Pharmacy‐Driven Interventions

• Changes from IV to PO therapy
• Dose adjustments
• Dose optimization
• Alerts in situation where therapy might be unnecessarily

duplicative

• Time‐sensitive automatic stop orders
• Detection and prevention of antibiotic‐related drug‐drug

interactions

• CDC. Core Elements of Hospital Antibiotic Stewardship Programs.

36

9/21/2017 13 ASP Structure

• ASPs should be co‐led by a physician with infectious disease and/or antimicrobial stewardship

training and a pharmacist

• Other members should include a clinical microbiologist and an infection preventionist
• Key support may include clinicians, quality improvement staff, laboratory staff, information

technology staff, and nurses

• The Joint Commission requires (when available)
• An infectious disease physician
• Infection preventionist(s)
• Pharmacist(s)
• Practitioner
• CDC. Core Elements of Hospital Antibiotic Stewardship Programs.

Fishman N. Infect Control Hosp Epidemiol. 2012; 33: 322–7. The Joint Commission. Jt Comm Perspect. July 2016; 36(7): 1, 3‐4, 8. 37

Joint Commission Requirements

Standard MM.09.01.01 – Effective January 1, 2017

• 1. Antimicrobial Stewardship is an Organizational

Priority

• 5. Implement CDC Core Elements of Hospital

Antimicrobial Stewardship Programs

• 2. Educate Hospital Personnel on Antimicrobial

Stewardship Practices

• 6. Use Organization‐Approved Multidisciplinary

Protocols

• 3. Educate Patients and Families on Appropriate

Antimicrobial Use

• 7. Collect, Organize, and Report Data on ASP
• 4. Multidisciplinary ASP Team Includes:
• Infectious Disease Physician
• Infection Preventionist(s)
• Pharmacist(s)
• Practitioner
• 8. Take Action on Improvement Opportunities

Identified in the ASP

38 The Joint Commission. Jt Comm Perspect. July 2016; 36(7): 1, 3‐4, 8.

CDC Core Elements of Hospital Antimicrobial Stewardship Programs

• Leadership commitment: Dedicating necessary human, financial, and

information technology resources.

• Accountability: Appointing a single leader responsible for program outcomes.

Experience with successful programs shows that a physician leader is effective.

• Drug expertise: Appointing a single pharmacist leader responsible for

working to improve antibiotic use.

• Action: Implementing recommended actions, such as systemic evaluation of
• ngoing treatment need, after a set period of initial treatment (for example,

“antibiotic time out” after 48 hours).

• CDC. Core Elements of Hospital Antibiotic Stewardship Programs.

39

9/21/2017 14 CDC Core Elements of Hospital Antimicrobial Stewardship Programs

• Tracking: Monitoring the antimicrobial stewardship program, which may

include information on antibiotic prescribing and resistance patterns

• Reporting: Regularly reporting information on the antimicrobial stewardship

program, which may include information on antibiotic use and resistance, to doctors, nurses, and relevant staff

• Education: Educating practitioners, staff, and patients on the antimicrobial

program, which may include information about resistance and optimal prescribing

• CDC. Core Elements of Hospital Antibiotic Stewardship Programs.

40

Que Questio ion 9

The Joint Commission requires which of the following in a hospital antimicrobial stewardship program:

• A. Staff education
• B. Patient education
• C. Pharmacy member(s)
• D. Tracking and reporting of outcomes
• E. All of the above

41

Initiatives at St. Claire Regional Medical Center

• St. Claire recently implemented its own ASP
• Primary interventions at St. Claire are a combination of preauthorization and PAF
• Protected antibiotics
• Carbapenems
• Linezolid
• Daptomycin
• > 3 days of piperacillin/tazobactam
• Lack of ID physician presents challenges
• ASP is primarily pharmacy‐driven

42

9/21/2017 15

Sinclair C. Antimicrobial Stewardship in a Rural Community Hospital.

• St. Claire Antibiogram

Sinclair C. Antimicrobial Stewardship in a Rural Community Hospital. 44

Future Initiatives at St. Claire

• Implementation of automatic stop dates for antibiotics
• Eventual protection of fluoroquinolone use
• Reductions in hospital CDI rates
• Automatic IV to PO transitions
• Facility‐specific treatment guidelines
• Allergy testing

45

9/21/2017 16

Que Questio ion 10

Antimicrobial Stewardship Programs (ASPs) are only effective at large academic medical centers.

True False

46

Summary

• 20‐50% of antibiotic prescriptions in the US are inappropriate
• Kentucky has one of the highest per capita prescription rates for antibiotics in the US
• Antibiotic resistance is increasing while the number of new antibiotics is decreasing
• Antimicrobial stewardship programs (ASPs) decrease inappropriate antimicrobial

usage, improve patient outcomes, and reduce costs

• Preauthorization and/or prospective audit & feedback strategies are the foundation
• f an ASP
• The Joint Commission requires that critical access hospitals have an antimicrobial

stewardship program as of January 1, 2017

47

References

• 1. Fishman N. Policy statement on Antimicrobial Stewardship by the Society for Healthcare Epidemiology of America (SHEA), the Infectious

Diseases Society of America (IDSA), and the Pediatric Infectious Diseases Society (PIDS). Infect Control Hosp Epidemiol. 2012; 33: 322–7. DOI: 10.1086/665010

• 2. Discovery of first mcr‐1 gene in E. coli bacteria found in a human in United States. Centers for Disease Control and Prevention Website.

https://www.cdc.gov/media/releases/2016/s0531‐mcr‐1.html. Published May 31, 2016. Accessed September 1, 2017.

• 3. CDC. Antibiotic Resistance Threats in the United States, 2013. Atlanta, GA: US Department of Health and Human Services, CDC; 2013.

Available at https://www.cdc.gov/drugresistance/threat‐report‐2013/pdf/ar‐threats‐2013‐508.pdf.

• 4. CDC. Core Elements of Hospital Antibiotic Stewardship Programs. Atlanta, GA: US Department of Health and Human Services, CDC; 2014.

Available at https://www.cdc.gov/getsmart/healthcare/pdfs/core‐elements.pdf.

• 5. Barlam TF, Cosgrove SE, Abbo LM, et al. Implementing an Antibiotic Stewardship Program: Guidelines by the Infectious Diseases Society of

America and the Society for Healthcare Epidemiology of America. Clin Infect Dis. May 2016; 62(10): e51‐e77. DOI: 10.1093/cid/ciw118

• 6. The Joint Commission. New Antimicrobial Stewardship Standard. Jt Comm Perspect. July 2016; 36(7): 1, 3‐4, 8. Available at

https://www.jointcommission.org/assets/1/6/New_Antimicrobial_Stewardship_Standard.pdf.

• 7. Brown KA, Khanafer N, Daneman K, Fisman DN. Meta‐Analysis of Antibiotics and the Risk of Community‐Associated Clositridium difficile
• Infection. Antimicrob Agents Chemother. May 2013; 57(5): 2326‐2332. DOI: 10.1128/AAC.02176‐12
• 8. Penicillin Allergy Testing: AAAAI Advocacy Priority. American Academy of Allergy, Asthma, and Immunology Website.

https://www.aaaai.org/about‐aaaai/advocacy/penicillin‐allergy‐testing. Updated 2017. Accessed September 1, 2017. 48

9/21/2017 17 References

• 9. Sinclair C. Antimicrobial Stewardship in a Rural Community Hospital. April 2016
• 10. Abbo LM, Cosgrove SE, Pottinger PS, et al. Medical students’ perceptions and knowledge about antimicrobial stewardship: how are we

educating our future prescribers? Clin Infect Dis. 2013; 57:631–8.

• 11. Davey P, Brown E, Charani E, et al. Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database Syst
• Rev. 2013; 4:CD003543.
• 12. Mehta JM, Haynes K, Wileyto EP, et al. Comparison of prior authorization and prospective audit with feedback for antimicrobial stewardship.

Infect Control Hosp Epidemiol. 2014; 35:1092–9.

• 13. Omidvari K, de Boisblanc BP, Karam G, Nelson S, Haponik E, Summer W. Early transition to oral antibiotic therapy for community‐acquired

pneumonia: duration of therapy, clinical outcomes, and cost analysis. Respir Med. 1998; 92:1032–9.

• 14. Laing RB, Mackenzie AR, Shaw H, Gould IM, Douglas JG. The effect of intravenous‐ to‐oral switch guidelines on the use of parenteral

antimicrobials in medical wards. J Antimicrob Chemother. 1998; 42:107–11.

• 15. Valiquette L, Cossette B, Garant MP, Diab H, Pepin J. Impact of a reduction in the use of high‐risk antibiotics on the course of an epidemic of

Clostridium difficile‐associated disease caused by the hypervirulent NAP1/027 strain. Clin Infect Dis. 2007; 45(suppl 2):S112–21.

• 16. Guglielmo B, Dudas V, Maewal I, et al. Impact of a series of interventions in vancomycin prescribing on use and prevalence of vancomycin‐

resistant enterococci. Jt Comm Qual Patient Saf. 2005; 31:469–75.

• 17. Hepburn MJ, Dooley DP, Skidmore PJ, Ellis MW, Starnes WF, Hasewinkle WC. Comparison of short‐course (5 days) and standard (10 days)

treatment for uncomplicated cellulitis. Arch Intern Med. 2004; 164:1669–74. 49

Antimicrobial Stewardship

JONATHAN PERDUE, PHARMD PGY1 PHARMACY RESIDENT

• ST. CLAIRE REGIONAL MEDICAL CENTER

09/23/2017 EMAIL ADDRESS: JONATHAN.PERDUE@ST‐CLAIRE.ORG

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