1. Robert G. Sawyer- University of Virginia

2.  None

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

5.  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

6.  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

7.  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

9. Nowak MA et al, Am J Health Syst Pharm 2012

12. Standiford HC et al, Inf Cont Hosp Epidemiol 2012

13. Valiquette L et al, Clin Infect Dis 2007

14. Boyles TH et al, PLOS One 2013

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

18. Doron S et al, Clin Ther 2013

20. Yam P et al, Am J Health Syst Pharm 2013

23. Linkin DR et al, Infect Cont Hosp Epidemiol 2007

25.  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

26. Eachempati SR et al, J Trauma 2009

28. 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)

29. Garnacho-Montero J et al, Intensive Care Med 2014

31.  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

32.  It’s worth it

33. Thank you rws2k@ virginia.edu