Table 1
Stewardship interventions to improve antimicrobial use as defined by CDC
Broad interventions
Antibiotic “time-outs” Reevaluation of the continuing need or election of antimicrobial
48 hours after the onset of the therapy
Prior authorisation Restrict the use of some antibiotics to ensure that use is reviewed
with an expert.
Prospective audit and feedback The audits are conducted by experts other than the treating team.
Pharmacy-driven interventions
Automatic changes from intravenous to oral antibiotic For selected antibiotics in adequate situations
Dose adjustments In case of organ dysfunction
Dose optimisation Optimising therapy for highly drug-resistant bacteria
Automatic alerts in situations where treatment might be
unnecessarily duplicative Simultaneous use of multiple antimicrobials with the same spectra
Time-sensitive automatic stop orders Specially in case of surgical prophylaxis
Detection and prevention of antibiotic-related drug–drug
interactions
Infection- and syndrome-specific interventions
Community-acquired pneumonia In compliance with guidelines, adjusting therapy to culture results
and optimising the duration of regimes
Urinary tract infections Eluding unnecessary urine cultures and treatment of asymptomatic
patients.
Skin and soft tissue infections Securing patients do not get antibiotics with wide broad spectra
and ensuring the correct duration of therapies
Empiric coverage of MRSA infection Stopping treatment for MRSA if the cause is methicillin-sensitive
Staphylococcus aureus
Clostridium difficile infections To stop futile antibiotics in all patients diagnosed with Clostridium
difficile infections
Treatment of culture proven invasive infections Adjusting antibiotics or discontinuing them
www.cdc.gov/antibiotic-use/healthcare/implementation/core-elements.html
clinicians should correctly interpret positive
cultures, identifying those patients with
colonisation without infection.
Biomarkers to guide AS in sepsis
There are several biomarkers used as infection
biomarkers. C-reactive protein and procalcitonin
(PCT) are the most broadly studied. PCT is
a biomarker produced by a host response in
bacterial infection. The half-life of PCT is about
24 hours and a progressive decrease in PCT levels
is seen in well-controlled infections. Diverse
studies show how PCT algorithms used to guide
initiation or duration of therapy decreases
antimicrobial consumption without increasing
adverse clinical outcomes. 23,24 A meta-analysis
aiming to summarise the effect of a procalcitonin
22
HHE 2018 | hospitalhealthcare.com
(PCT)-guided antibiotic treatment on outcomes in
acute lower respiratory tract infections showed
significant reductions in antibiotic duration. 25
Nevertheless, PCT is not only an infection
biomarker, but can also be affected in
inflammatory conditions, so it is difficult to
interpret in surgical patients. It is accepted that
PCT levels <0.5ng/ml or a decrease of 80% of the
highest PCT peak is useful to stop antibiotics and
predicting good outcome but this algorithm failed
in a single-centre study in patients with septic
shock secondary to intra-abdominal infection. 26 In
a study in children admitted to the intensive care
unit after cardiopulmonary bypass, Jordan et al
demonstrated that PCT was useful in diagnosing
bacterial infection, but increased the cut-off on
PCT to 2ng/ml, higher than in medical