Factors Leading to the Spread of Vancomycin-Resistant Enterococci in US Hospitals Factors Antimicrobial pressure Environmental contamination and survival Suboptimal clinical laboratory recognition and reporting Inadequate compliance with hand washing and barrier precautions Introduction of Unrecognized carriers From community settings (e.g., nursing homes) Unrecognized “silent” carriage and prolonged fecal carriage Intrahospital and interhospital transfer of Colonized patients Maritone WJ. Infect Control Hosp epidemiol. 1998;19:

Components of an Effective Antimicrobial Stewardship Program Inclusion of an infectious diseases physician, clinical pharmacist, clinical microbiologist, information system specialist, infection control professional, and hospital epidemiologist in the core team Collaboration with hospital infection control and pharmacy and therapeutics committees Support and collaboration of hospital administration, medical staff leadership and local providers, and function under auspices of quality assurance and patient safety Effective negotiation with hospital administration to obtain adequate authority, compensation and expected outcomes for the program Support of hospital administration for the necessary infrastructure to measure and track antimicrobial use Completion of a prospective audit with intervention and feedback Determination of formulary restriction and preauthorization

Antibiotics with Phase III Data Completed or Enrolling, 2007 ClassAgentSpectrumUnique propertiesPhase III Trials LipoglycopeptideDalbavancin Oritavancin Telavancin Gram + Long t 1/2 ; weekly dosing Daily dosing cSSSI cSSSI, BSI, HAP cSSSI CarbapenemDoripenemGram – More than Gram + Active against some meropenem-resistant isolates HAP, VAP, complicated pelvic infections, pyelonephritis CephalosporinCeftaroline Ceftobiprole Gram +/Gram – Gram +/Gram - Has MRSA activity Currently recruiting for cSSSI cSSSI, including mixed infections, HAP, CAP Dihydrofolate reductase inhibitor IclaprimGram +/Gram -I.V. and possibly POcSSSI FluoroquinoloneGarenoxacinGram +/Gram -POcSSSI, ACEB, CAP, sinusitis, acute pelvic infection ACEB, acute exacerbations of chronic bronchitis, BSI, bloodstream infections; CAP, community-acquired pneumonia; cSSSI, complicated skin and skin structure infections; HAP, hospital-acquired pneumonia; I.V., intravenously; MRSA, methicillin- Resistant, Staphylococcus aureus; PO, orally; VAP, ventilator-associated pneumonia Zaas AK. Infect Dis Spec Ed. 2007:9-15