Robert G. Sawyer- University of Virginia

 None

 What it means  Effects on outcomes  How frequently is it implemented  Notes on de-escalation

 A physician  A pharmacist  A clinical microbiologist  An infection preventionist Dellit TH et al, Clin Infect Dis 2007 SHEA/IDSA/PIDS statement, Infect Cont Hosp Epidemiol 2012

 Prospective audit with intervention and feedback. Prospective audit of antimicrobial use with direct interaction and feedback to the prescriber, performed by either an infectious diseases physician or a clinical pharmacist with infectious diseases training, can result in reduced inappropriate use of antimicrobials  Formulary restriction and preauthorization. Formulary restriction and preauthorization requirements can lead to immediate and significant reductions in antimicrobial use and cost Dellit TH et al, Clin Infect Dis 2007

 Education  Guidelines and clinical pathways  Antimicrobial cycling  Antimicrobial order forms  Combination therapy  Streamlining or de-escalation of therapy  Dose optimization  Parenteral to oral conversion Dellit TH et al, Clin Infect Dis 2007

Nowak MA et al, Am J Health Syst Pharm 2012

Standiford HC et al, Inf Cont Hosp Epidemiol 2012

Valiquette L et al, Clin Infect Dis 2007

Boyles TH et al, PLOS One 2013

Teo J et al, Eur J Clin Microbiol Infect Dis 2012

Doron S et al, Clin Ther 2013

Yam P et al, Am J Health Syst Pharm 2013

Linkin DR et al, Infect Cont Hosp Epidemiol 2007

 Removing one of multiple antimicrobials that is unnecessary, e. g., stopping empiric vancomycin when an infection is found to be caused by Pseudomonas aeruginosa  Exchanging one antimicrobial active against an isolated pathogen for another one also active but with a narrower spectrum, e. g., change piperacillin-tazobactam to ciprofloxacin for an E. coli infection sensitive to both agents

Eachempati SR et al, J Trauma 2009

Garnacho-Montero J et al, Intensive Care Med 2014  Withdrawal of one antimicrobial (group I)  Withdrawal of two of the antimicrobials empirically prescribed (group II)  Switch to a new antimicrobial with narrower spectrum (group III)  Withdrawal of at least one antimicrobial plus change of another drug to a new one with narrower spectrum (group IV)

Garnacho-Montero J et al, Intensive Care Med 2014

 Takes a fair amount of work  Several ways to do it  Less antimicrobial use ⇒ Saves money  Different antimicrobial use patterns  Probably less C. difficile  Rearranges resistance  Same length of stay  Same number of pine boxes

 It’s worth it

Thank you virginia.edu