Minnesota Guide
to a Comprehensive
Antimicrobial Stewardship Program
September 2012
Minnesota Department of Health
Infectious Disease Epidemiology, Prevention and Control
651-201-5414
TDD/TTY 651-201-5797
www.health.state.mn.us
Table of Contents
Introduction……………………………………………………………………………………….…..…….…. 3
Minnesota Antimicrobial Stewardship Steering Group…………………….…….….……… 4
Getting Started……………………………………………………………………………….………….…..…. 5
Antimicrobial Stewardship Program (ASP) Infrastructure………………….….…….…..… 6
ASP Strategies…………………………………………………………………………………….…….……... 8
List of Appendices……………………………………………………………………………………….…… 13
Appendix A: ASP Resources.………………….……………………………………………..…...…… 14
Appendix B: Antimicrobial Prescribing Practices & Utilization Assessment…...... 16
Appendix C: Antimicrobial Stewardship Perception Survey..…………..…….……..… 18
Appendix D: Antimicrobial Use Prevalence Survey…….………….…………………....…. 20
Minnesota Guide to a Comprehensive Antimicrobial Stewardship Program 9/19/2012
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Introduction
Unfortunately, we are now encountering infections for which there are no good therapeutic
options. Now more than ever, antimicrobial stewardship is of the utmost importance as a way
to optimize the use of antimicrobials, stem the tide of antimicrobial resistance, and improve
patient outcomes.
We think it is vital for there to be an antimicrobial stewardship program (ASP) in every
Minnesota hospital. An institutional philosophy that supports these elements is critical to a
successful and sustainable ASP, including the support and commitment of institutional
leadership.
The Minnesota Guide to a Comprehensive Antimicrobial Stewardship Program was developed
by the Minnesota Antimicrobial Stewardship Steering Group and is intended to guide the
development and implementation of an ASP, taking into consideration the wide variation in
financial and personnel resources within facilities. This Guide is comprised of three sections:
1) infrastructure to support the ASP; 2) ASP strategies – core and expanded; and 3) appendices
with resources. Healthcare facilities are encouraged to share this public resource with all
interested collaborators.
Minnesota Guide to a Comprehensive Antimicrobial Stewardship Program 9/19/2012
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Minnesota Antimicrobial Stewardship Steering Group
Leslie Baken, MD
Park Nicollet Health Services
Ritu Banerjee, MD, PhD
Mayo Clinic
Kim Boeser, PharmD
University of Minnesota Medical Center - Fairview
Aaron DeVries, MD, MPH
Minnesota Department of Health
Lynn Estes PharmD, RPh
Mayo Clinic
Greg Filice, MD
Minneapolis VA Health Care System
Jane Harper, BSN, MS, CIC
Minnesota Department of Health
Jessica Holt, PharmD, BCPS-ID
Abbott Northwestern Hospital
Johnson Innis, PharmD
Gillette Children’s Hospital
Paul Jensen, PharmD
Children’s Hospitals & Clinics of Minnesota
Susan Kline, MD, MPH
University of Minnesota Medical Center – Fairview
Gary Kravitz, MD, FACP, FIDSA, FSHEA
St. Paul Infectious Disease Associates
Jeffrey Larson, PharmD
Park Nicollet Health Services
Lindsey Lesher, MPH
Minnesota Department of Health
Ruth Lynfield, MD
Minnesota Department of Health
Mindy McFarren, MS MT(ASCP)
HealthEast Care System
Jessica Nerby, MPH, CLS, CIC
Abbott Northwestern Hospital
William Pomputius, MD
Children’s Hospitals & Clinics of Minnesota
Jean Rainbow, RN, MPH
Minnesota Department of Health
Linn Warnke, RN, MPH
Minnesota Department of Health
Boyd Wilson, MT(ASCP), MS, CIC
HealthEast Care System
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Getting Started
At a minimum, an antimicrobial stewardship program (ASP) includes a physician and pharmacist
motivated to develop expertise in antimicrobial stewardship and become familiar with local prescribing
and antimicrobial resistance trends. First steps for an ASP are outlined below.
 Review key published ASP literature (Appendix A #1-6).
 Look for clues of existing ASP elements:
• Microbiology lab:
o Develops or has access to a local antibiogram
• Pharmacy or pharmacy & therapeutics (P & T) committee:
o Selects antimicrobials that are available on the facility formulary
o Provides recommendations that reduce medication redundancy
o Advises about parenteral-to-oral medication conversions
• Medical leadership:
o Involvement in patient safety committees
o Reviews/debriefs cases during morbidity and mortality rounds
• Infection prevention:
o Promotes policies and procedures to prevent and control multidrug-resistant organisms
• Information technology:
o Has the ability to query electronic medical records
 Acquire access to antimicrobial use and microbiology data:
• Coordinate with necessary staff to access baseline data (e.g. antimicrobial budget, antimicrobial
utilization, antimicrobial resistance patterns)
 Get the ear of senior leadership:
• Explore how ASP elements align with the facility’s stated values
• Identify an administrative advocate to promote the value of an ASP in your facility
 Identify a physician or pharmacist to champion the ASP. Desirable qualities include:
• Basic knowledge of antibiotics
• Good team player
• Interested in playing a leadership role in • Recognizes the importance of a
his/her local community
culture of patient safety
• Respected by his/her peers
Begin building an Antimicrobial Stewardship Program using the
Minnesota Guide to a Comprehensive Antimicrobial Stewardship Program
Minnesota Guide to a Comprehensive Antimicrobial Stewardship Program 9/19/2012
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ASP Infrastructure
In order for an ASP to be effective, a solid foundation is essential to identify and implement ASP strategies. This
foundation includes the ASP infrastructure components (outlined below) such as clarifying the ASP charge;
identifying ASP champions, team members, and key stakeholders; developing an implementation plan; and
determining communication, education, and feedback channels. Facilities are encouraged to implement ASP
infrastructure components that are most appropriate to their patient populations and/or units.
1. Identify ASP physician and pharmacist champions
a. Optimally, physician and pharmacist co-champion the ASP
b. At a minimum, either a physician or pharmacist serves as the ASP champion
c. Physician with infectious diseases training or expertise (preferred)
d. Clinical pharmacist with infectious diseases training or expertise (preferred)
2. Engage a member of senior leadership to support the ASP Team and advocate for ASP resources
3. Establish an interdisciplinary ASP Team with a designated champion to oversee implementation
a. If an ASP Team is not feasible, utilize existing facility committees with expertise regarding ASP
principles (e.g. Infection Prevention & Control, Medical Executive, Pharmacy or Pharmacy &
Therapeutics [P & T], etc.)
4. Conduct baseline facility assessments. For example:
a. Antimicrobial Prescribing Practices and Utilization Assessment (Appendix B)
b. Antimicrobial Stewardship Perception Survey (Appendix C)
5. Utilize information collected in baseline facility assessments to:
a. Determine ASP goals and objectives that align with the facility mission/values
b. Assess for improvement opportunities
c. Identify and prioritize ASP strategies
6. Develop, define, and document facility expectations. For example:
a. Expectations that promote a culture that encourages feedback to prescribers regarding
antimicrobial use
b. Expectations for implementation of the ASP (e.g., unit(s), timelines, roles/responsibilities, strategies,
evaluation)
c. Expectations ensuring that ASP team members have dedicated/compensated time for ASP activities
d. Expectations regarding the flow of communication among stakeholders within the facility (i.e. to
whom the ASP will provide information and from whom the ASP will request information)
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7. Develop, define, and document ASP Team member roles and responsibilities; consider including:
a. ASP Team leadership
b. ASP planning, implementation, and evaluation
c. Coordination of ASP education (prescribers, front-line staff, leadership, patients)
d. P & T committee liaison
e. Data coordination and management – pharmacy, microbiology, healthcare-associated infections
f. Expertise on antimicrobial use, including safety, efficacy, and cost-effectiveness
g. Coordination of providing antimicrobial use feedback
8. Develop a process to communicate ASP goals, objectives, and facility expectations for implementation of
ASP strategies to key stakeholders
a. Develop a process to communicate feedback from stakeholders to the ASP Team regarding ASP
goals, objectives, and strategies
9. Develop an ASP operational plan, including: timeline, budget, rollout of selected ASP strategies, frequency of
ASP Team meetings, organizational structure (e.g., ASP Team relationship to P & T committee), etc.
10. Communicate principles of antimicrobial stewardship to key stakeholders (i.e. prescribers, microbiologists,
pharmacists, infection preventionists, direct patient care staff, administration, etc.)
a. Rationale for engaging in selected ASP strategies
b. Best practices for ASP as described in current literature
i. Tailor to stakeholders’ roles
11. Develop a process for the ASP Team to regularly communicate with the Infection Prevention and Control
Department/Committee regarding healthcare-associated infection surveillance data (e.g. hospital-onset
bacteremias, CLABSI, CAUTI, MDRO, CDI)
12. Evaluate ASP Team membership on a regular basis (annually, at a minimum) and expand as needed.
Consider including staff from:
a. Clinical microbiology
b. Infection prevention
c. Hospital epidemiology
d. Information system technology
e. Patient safety/quality improvement
f. P & T committee
g. Medical leadership committee
h. Clinical practice groups such as emergency medicine, hospitalists
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ASP Strategies
The ASP strategies are presented as a two-tiered approach (core and expanded). This allows facilities to
identify ASP strategies that are most appropriate to their patient populations and/or units to maximize
the impact of the ASP on patient outcomes and costs. Core strategies are baseline approaches that
should always be in place as part of a comprehensive ASP. Expanded ASP strategies should be
implemented as possible and as are relevant to the facility/unit.
1. Review formulary, pharmaceutical contacts, and identify restricted antimicrobials
Core strategies
a) Review pharmacy formulary and pharmaceutical contracts at least annually
b) Identify the costs associated with each antimicrobial
c) Identify all antimicrobials available on the formulary and assess for duplicative agents
d) Implement a process for removing duplicative antimicrobials from the formulary
e) Determine antimicrobials that should be restricted
f) Define criteria for use of restricted antimicrobials
g) Implement a process to ensure that antimicrobials from the formulary are aligned with
antimicrobial susceptibility testing performed by microbiology
Expanded strategies
a) Determine a process for physicians to order restricted antimicrobials (e.g. physician/pharmacist
consultation or preauthorization)
b) Implement a process for communication and reinforcement of the antimicrobial formulary
c) Implement a process to prospectively audit (via rounds or remotely) use of restricted
antimicrobials within the facility
d) Implement a process to prospectively audit (via rounds or remotely) use of additional
antimicrobials within the facility
e) Identify mechanisms through revision of pharmaceutical contracts to reduce costs associated
with specific antimicrobials
f) Publish/communicate comparative cost/day information of antimicrobials
2. Review use of an antimicrobial or antimicrobial class within the facility (e.g. drug utilization
evaluation [DUE]; see Appendix A #16-17)
Core strategies
a) Select an antimicrobial or antimicrobial class of interest to the facility and complete a DUE;
factors to consider: utilization, resistance, toxicity, cost, appropriateness of use
b) Prospectively audit use of the selected antimicrobial or antimicrobial class on a specific hospital
unit or throughout the hospital
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c) Identify trends, such as:
• Utilization rates
• Drug dose, route, frequency
• Days of therapy
• Indications for use
• Appropriateness of use
• Toxicity
• Adverse drug events
• Temporal utilization trends in the facility
• Other notable prescribing trends
d) Utilize standard antimicrobial use definitions for analyses (e.g. defined daily dose, days of
therapy; Appendix A #16-17)
e) Communicate aggregate antimicrobial utilization data to stakeholders
Expanded strategies
a) Expand antimicrobial audits
• Identify and prospectively audit additional antimicrobials of concern to the facility
• Consider audits by unit and/or prescriber
• If previously limited to select units, broaden the audit to other units in the facility
b) Utilize audit data to identify individual provider (e.g. surgeons, internal medicine, critical care)
and/or provider group (e.g. medical ICU, emergency department) use of antimicrobial agents
c) Provide prescriber-specific antimicrobial use data to prescribers
d) Develop a process to communicate patient-specific ASP Team antimicrobial recommendations
to prescribers
e) Develop a process for tracking adherence to ASP Team recommendations for patient-specific
antimicrobial treatment
f) Utilize National Healthcare Safety Network (NHSN) to monitor and analyze antimicrobial use
and/or resistance data (e.g., NHSN Antimicrobial Use and Resistance Module)
3. Utilize an antibiogram
Core
a) Develop or gain access to a facility-specific antibiogram. If a facility-specific antibiogram is not
feasible, utilize a regional antibiogram
b) Utilize Clinical and Laboratory Standards Institute (CLSI) guidelines in development of an
antibiogram
c) Disseminate or ensure antibiogram is electronically available to prescribers and stakeholders
d) Provide education to prescribers regarding the purpose and use of an antibiogram
Expanded
a) Develop a process for periodically updating antibiogram components:
Minnesota Guide to a Comprehensive Antimicrobial Stewardship Program 9/19/2012
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• Organisms included
• Antimicrobial susceptibility trends
b) Develop antibiograms for patient groups/populations such as:
• Adult patients
• Pediatric patients
• Hospital units (e.g. medical ICU, emergency department)
• Special patient-specific populations (e.g. patients with cystic fibrosis)
• Inpatients
• Outpatients
• Long-term care patients
• Specimen sources (e.g. urine, blood, respiratory)
4. Optimize antimicrobial prescribing
Core
a) Adopt and communicate facility expectations that prescribers will follow evidence-based
practice guidelines for infectious syndromes
b) Review a sample of microbiologic test results to identify bug-drug mismatches
• Are prescribed antimicrobials indicated for identified organisms?
• Are prescribed antimicrobials indicated based on antimicrobial susceptibility testing
results for identified organisms?
Expanded
a) Implement a process to identify bug-drug mismatches in real time
b) Develop a process to communicate parenteral-to-oral conversion opportunities to prescribers in
a timely manner via phone, email, medical record, etc.
c) Develop and implement a process for streamlining or de-escalating therapy
d) Develop and implement a process for dose optimization
e) Develop and implement a process for monitoring physiologic response to antimicrobials (e.g.
serum levels, organ function, signs of toxicity)
f) Develop and implement a process for reducing redundant therapy
g) Develop and implement a process for establishing reasonable duration of therapy for infectious
syndromes (e.g. after 72 hours of therapy)
5. Review clinical syndromes
Core
a) Select 1 – 2 clinical syndromes/diagnoses of importance to the facility for which prescriber
documentation of treatment indication will be reviewed using current evidence-based practice
guidelines including use of antimicrobials for clinical infection vs colonization (e.g. Infectious
Diseases Society of America guidelines, see Appendix A #7). Consider the following examples:
• Bacteriuria/urinary tract infection
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•
•
•
•
Skin and soft tissue infections
Intravascular catheter-related infections
Pneumonia
Clostridium difficile infection
Expanded
a) Develop or adopt guidelines and clinical pathways/algorithms for antimicrobial treatment and
management of selected syndrome(s); this may include the use of:
• Documentation of clinical indications at time of order entry for antimicrobial treatment
• Order sets and clinical pathways
• Appropriate use of diagnostics
• Electronic medical records
• Computer physician order entry (CPOE)
• Clinical decision support for ordering antimicrobials
b) Select additional clinical syndromes
c) Audit utilization of evidence-based practice guidelines for the selected clinical syndromes
d) Implement a process for determining utilization of evidence-based practice guidelines for the
selected clinical syndrome(s)
6. Review and analyze patient outcome data
Core
a) Develop and implement a process for monitoring and analyzing patient safety indicators
a. Adverse events associated with specific antimicrobials
b. Days of antimicrobial therapy
Expanded
a) Develop and implement a process for monitoring and analyzing additional patient safety
indicators
• Hospital-onset C. difficile infection
• ICU length of stay
• Mortality index
7. ASP Evaluation
Core
a) Develop and implement a process to evaluate the impact of the ASP; consider monitoring the
following components over time (e.g. baseline, quarterly, annually) and comparing results to
previous time points:
• Cost of all antimicrobials within the facility
• Utilization of all antimicrobials within the facility
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•
•
Antimicrobial resistance within the facility
Adherence to strategies recommended by ASP Team
Expanded
a) Expand the ASP evaluation; consider monitoring the additional components over time (e.g.
quarterly, annually):
• Trends of hospital-onset C. difficile infections
• Trends of multidrug-resistant organisms (e.g. VRE, MRSA. CRE)
• Utilization of specific antimicrobials within the facility
• Utilization of specific antimicrobials within the facility by unit/specialty
• Cost of all antimicrobials by unit/specialty
• Cost of dedicated time of ASP Team members
• Mean duration of antimicrobials over time (e.g. patients that received antimicrobials for
< 3 days)
• Antimicrobial cost per admission or per patient-day
• Number of bug-drug mismatches over time
b) Develop an annual antimicrobial stewardship report and disseminate to prescribers and
stakeholders
• Identify goals and needs
• Identify successes
• Identify challenges and threats to success
Next steps for the ASP
After the ASP has been implemented and evaluated, discuss plans with internal and external
stakeholders regarding expansion of the ASP into facility-associated healthcare settings (e.g. ambulatory
care, long-term care, ambulatory surgery centers). Additionally, ASP team members should consider
serving as an expert resource for regional, state, or national ASP collaboratives/committees with the
goal of assisting other facilities or healthcare delivery systems to establish or improve an ASP.
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Appendices
The appendices included in this Guide are optional tools that can be used to supplement your
facility’s ASP.
Appendix A includes a list of key peer-reviewed articles regarding antimicrobial stewardship
and resources for implementing an ASP such as practice guidelines, drug utilization evaluation
templates, and tools for implementing ASP strategies.
Appendix B is a tool to assess antimicrobial practices and utilization in your facility. This tool
can be used as a starting point to identify strengths and gaps that need to be addressed or
improved upon.
Appendix C is a survey developed to assess clinicians’ perceptions of an antimicrobial
stewardship program, prescribing practices, and antimicrobial resistance in the facility.
Appendix D is an antimicrobial use prevalence survey to evaluate the use of antimicrobials over
a period of time or at a single point in time in the facility. It can be conducted facility-wide or in
specific areas/units of the facility that may be targeted as part of your ASP.
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Appendix A: ASP Resources
Policy Statements, Position Papers, and Guidelines
1. SHEA/IDSA/PIDS. 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). Infection Control and Hospital Epidemiology 2012;33(4):322-327.*
2. APIC/SHEA Position Paper. Moody JM, Cosgrove SE, Olmsted R, et al. Antimicrobial stewardship: A
collaborative partnership between infection preventionists and healthcare epidemiologists. Infection
Control and Hospital Epidemiology 2012;33(4):328-330. *
3. Dellit TH, Owens RC, McGowan JE, et al. IDSA and SHEA guidelines for developing an institutional
program to enhance antimicrobial stewardship. Clinical Infectious Diseases 2007;44:159-77. *
Additional Resources
4. Infection Control and Hospital Epidemiology Special Topic Issue: Antimicrobial Stewardship.
2012;33(4):319-437. Available at: http://www.jstor.org/stable/10.1086/663249 *
5. Clinical Infectious Diseases Supplement. Antimicrobial stewardship for the community hospital:
Practical tools & techniques for implementation. 2011;53(S1):S15-S30. *
6. Fishman N. Antimicrobial stewardship. American Journal of Medicine 2006;119(6A):S53-S61. *
7. Infectious Diseases Society of America. Practice Guidelines. Available at:
http://www.idsociety.org/IDSA_Practice_Guidelines/
8. Goff DA, Bauer KA, Reed EE, et al. Is the “low-hanging fruit” worth picking for antimicrobial
stewardship programs? Clinical Infectious Diseases 2012;55(4):587-92.
9. Special issue: Antimicrobial stewardship. The Journal of Human Pharmacology and Drug Therapy
2012;32(8). Available at: http://www.accp.com/pharmacotherapy
10. Medscape Education Infectious Diseases. Cosgrove SE, Fishman NO, Rybak MJ, Seo SK, Septimus EJ,
Trivedi KK. Antimicrobial stewardship: Practical strategies for the healthcare team. 2012. CME/CE
available at: http://www.medscape.org/viewprogram/32553?src=0_mp_cmenl_0
11. Clinical Infectious Diseases Supplement. Combating antimicrobial resistance: Policy
recommendations to save lives. 2011;52(S5):S397-S428.
12. Greater New York Hospital Association / United Hospital Fund. Antimicrobial stewardship toolkit:
Best practices from the GNYHA/UHF antimicrobial stewardship collaborative. 2011. Available at:
www.gnyha.org/antimicrobial
* Indicates key ASP literature
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13. CDC. “Antimicrobial Stewardship for the Community Hospital: Practical Tools & Techniques for
Implementation" online webinar. 2010. CME available at:
http://www.cdc.gov/getsmart/healthcare/learn-from-others/CME/antimicrobialstewardship.html#Accreditation
14. Hospital Pharmacy Supplement: Key Aspects of a Successful Antibiotic Stewardship Program. 2010.
Available at:
http://www.proce.com/monographs/HospitalPharmacyJournalNov2010_AntibioticStewardship.pdf
15. Spellberg B, Guidos R, Gilbert D, et al. The epidemic of antibiotic-resistant infections: A call to action
for the medical community from the Infectious Diseases Society of America. Clinical Infectious
Diseases 2008;46:155-64.
Drug Use Evaluation Resources
16. American Society of Health-System Pharmacists. ASHP guidelines on medication-use evaluation.
American Journal of Health-System Pharmacy. 1996;53:1953-5. Available at:
http://www.ashp.org/DocLibrary/BestPractices/FormGdlMedUseEval.aspx
17. World Health Organization. Drug and Therapeutics Committees - A Practical Guide. 6.5 Drug use
evaluation (DUE) (drug utilization review). 2003. Available at:
http://apps.who.int/medicinedocs/en/d/Js4882e/8.5.html#Js4882e.8.5
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APPENDIX B: ANTIMICROBIAL PRESCRIBING PRACTICES & UTILIZATION
ASSESSMENT
This assessment was developed to evaluate antimicrobial prescribing and utilization in your facility.
ASP Team
1.
Has a physician or pharmacist been identified to champion the ASP?
2.
Have the ASP Team members been identified?
3.
Have the ASP Team members reviewed the key literature? (See
Getting Started document, p. 5.)
Has the ASP Team determined how ASP elements align with the
facility’s stated values?
Has the ASP Team approached senior leadership about the
importance of an antimicrobial stewardship program?
4.
5.
a.
Yes
No
Yes
No
If Yes, specify:
Infectious diseases physician
Clinical pharmacist
Clinical microbiologist
Infection preventionist
Hospital epidemiologist
Patient safety/quality
Other, specify:
Yes
No
Yes
No
Yes
No
If yes, describe outcome of discussion and resulting action items.
Antimicrobial Data
6.
Does the ASP Team have access to antimicrobial use data?
Yes
No
7.
Does the ASP Team review the facility’s formulary at least annually?
Yes
No
8.
Does the facility have defined criteria for use of restricted-use
antimicrobials?
Yes
No
Yes
No
10. Is your facility able to obtain unit-specific microbiology data?
Yes
No
11. Is an antibiogram developed for your facility?
Yes
No
a.
List restricted-use antimicrobials:
b.
Describe the criteria for use of restricted-use antimicrobials:
Microbiology Practices
9. Does your facility have an in-house microbiology lab?
a.
If no, where are microbiology services performed?
a.
If no, do you have access to an antibiogram at the regional or
healthcare system level?
Yes
No
b.
If yes, how often (monthly, quarterly, annually)?
Yes
No
Yes
No
12. Can unit-specific antibiograms be developed?
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13. Is there a process in place to communicate microbiology testing
results to providers (negative and positive results)?
a.
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
If yes, describe the process (include how and in what timeframe)
Infectious Clinical Syndromes
14. What are the top three most common infectious clinical syndromes
at your facility (known or estimated)?
15. Has the facility adopted or developed guidelines and clinical
pathways/algorithms for antimicrobial treatment and management
of common infectious clinical syndromes?
a.
1)
2)
3)
If yes, list the guidelines and clinical pathways/algorithms
16. Does the facility have surgical prophylaxis order sets that include
antimicrobials?
a. If yes, describe antimicrobial, dose, and duration specifications
following the procedure:
Antimicrobial Prescribing
17. Is there a process in place in your facility for infectious diseases
physician or pharmacist to review antimicrobial prescribing?
a.
If yes, describe the process:
18. Is there a process in place to identify bug-drug mismatches in your
facility?
a. If yes, is the process initiated by microbiology test results,
antimicrobial prescribing, both, or other method?
19. Is there a process to communicate parenteral-to-oral conversion
opportunities to prescribers in a timely manner via phone, email,
medical record, or other method?
a.
If yes, describe the process:
20. Does the facility have computer physician order entry (CPOE)?
a.
If yes, does if include antimicrobials?
Yes
No
b.
If yes, does it include all units/areas of the hospital?
Yes
No
Yes
No
21. Does the facility have a process for monitoring adverse events
associated with antimicrobials?
a.
If yes, describe the process:
22. What are the barriers to ASP implementation in your facility? Check
all that apply.
Financial considerations/cost
Opposition from prescribers
Resistance from administration
Other clinical initiatives
Personnel shortages
None of the above
Other, specify:
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Appendix C: Antimicrobial Stewardship Perception Survey 1
This survey is intended to assess clinicians’ perceptions of an antimicrobial stewardship program,
antimicrobial prescribing practices (your own and the facility’s practices), and the scope of the
antimicrobial resistance in the facility.
Please indicate your agreement or disagreement with the following statements about your facility.
Thank you very much for your time.
ANTIMICROBIAL RESISTANCE: SCOPE OF THE PROBLEM AND KEY CONTRIBUTORS
1.
Antibiotic resistance is a significant problem in this
institution.
Patient rooms are cleaned according to hospital
cleaning protocol once a multidrug-resistant
organism (MDRO) patient has been discharged.
Adherence to hand-hygiene protocols is excellent at
this institution.
This institution does NOT do enough to control the
development of resistant organisms through
surveillance.
This institution does NOT provide adequate staff
education regarding MDROs.
A patient is likely to develop a MDRO infection
during their stay at this institution.
2.
3.
4.
5.
6.
ANTIBIOTIC PRESCRIBING PRACTICES
7.
Microbiology lab results are efficiently
communicated to the treating physician.
I regularly refer to/consider the antibiotic
susceptibility patterns at this institution (e.g., the
institutional antibiogram) when empirically
prescribing antibiotics.
If medically appropriate, intravenous antibiotics
should be stepped down to an oral alternative after
three days.
Restrictions on antibiotics impair my ability to
provide good patient care.
Antibiotics are overused at this institution.
More judicious use of antibiotics would decrease
antimicrobial resistance.
8.
9.
10.
11.
12.
Strongly
Disagree
Disagree
Neither
Agree
Strongly
Agree
Strongly
Disagree
Disagree
Neither
Agree
Strongly
Agree
Survey adapted from Greater New York Hospital Association/United Hospital Fund; survey based on the AHRQ
Hospital Survey on Patient Safety Culture. http://www.ahrq.gov/qual/patientsafetyculture/hospsurvindex.htm
1
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ANTIMICROBIAL STEWARDSHIP PROGRAMS
(A formal program that monitors and manages the appropriate use of antibiotics.)
Strongly
Disagree
Disagree
13. Antimicrobial stewardship programs improve patient
care.
14. Antimicrobial stewardship programs reduce the
problem of antimicrobial resistance.
15. Antimicrobial stewardship programs impact this
institution’s infection rates.
16. This institution has an effective antimicrobial
stewardship program.
17.
18.
19.
20.
Neither
Agree
Strongly
Agree
My individual efforts at antimicrobial stewardship
minimally impact this institution’s resistance problem.
This institution does NOT provide adequate training on
antimicrobial prescribing and use.
Additional staff education on antimicrobial prescribing
is needed.
Prescribing physicians are the only disciplines who
need to understand antimicrobial stewardship.
BACKGROUND INFORMATION
1.
What is your primary work area or unit in this institution? (Please check ONE answer)
Many different units/No specific unit
Medicine (non-surgical)
Intensive care unit (any type)
Radiology
Surgery
Psychiatry/mental health
Anesthesiology
Obstetrics
Rehabilitation
Other, please specify
Pediatrics
Pharmacy
Emergency department
Laboratory
2.
How long have you worked in this institution?
Less than 1 year
11 to 15 years
1 to 5 years
16 to 20 years
6 to 10 years
21 years or more
3.
What is your staff position in this institution?
Attending/Staff physician
Physician assistant
Resident physician/Intern
Nurse practitioner
Fellow
Infection control practitioner
Pharmacist
4.
Other, please specify
How long have you worked in your current specialty or profession?
Less than 1 year
6 to 10 years
16 to 20 years
1 to 5 years
11 to 15 years
21 years or more
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Appendix D: Antimicrobial Use Prevalence Survey
Objective
The objective of the antimicrobial use prevalence survey is to evaluate the use of antimicrobials over a period of
time or at a single point in time. The prevalence survey may be conducted facility-wide or focus on high-risk areas
for antimicrobials that may be targeted as part of the ASP. The aims of the survey may include:
• Establishing baseline antimicrobial use within the hospital
• Identifying prescribing patterns
• Collecting data to identify ASP goals and strategies
• Benchmarking practices within the facility over time
Instructions
•
•
•
•
•
•
•
Select location(s) for the prevalence survey
Select the desired information that will be evaluated (consider collecting patient age and gender,
antimicrobials used, dose per administration, number of doses per day, administration route, infection
site, duration of surgical prophylaxis, compliance with hospital antimicrobial guidance, indication for
therapy, etc)
Select the time period that the prevalence survey will include (1 day, 1 week, 1 month, etc)
Collect denominator data. The denominator should include all patients admitted to the included unit(s). It
may be helpful to select a time point during the day for which to include patients that are present and not
discharged from the unit at the time of the survey (i.e., include all patients present on the unit and not
discharged at 8:00 AM).
Collect numerator data. Include patients that received:
− ≥ 1 antimicrobial for treatment or medical prophylaxis; and/or
− At least one dose of an antimicrobial for surgical prophylaxis (24 hours prior to the time point
selected [i.e., 24 hours prior to 8:00 AM on the day(s) of the survey])
Review medical records of patients included in the prevalence survey for the information to be evaluated
Analyze and summarize the antimicrobial use prevalence survey data (see steps below)
Definitions
Community-onset infection: infection identified (indicated by specimen collection date) ≤ 3 days after admission to
the facility (i.e., days 1, 2, or 3 of admission).
Hospital-onset infection: infection identified (indicated by specimen collection date) > 3 days after admission to
the facility (i.e., on or after day 4)
Resources
English National Point Prevalence Survey on Healthcare-associated Infections and Antimicrobial Use, 2011
www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/HCAI/HCAIPointPrevalenceSurvey/
Aldeyab MA, Kearney MP, McElnay JC, et al. A point prevalence survey of antibiotic use in four acute-care teaching
hospitals utilizing the European Surveillance of Antimicrobial Consumption (ESAC) audit tool. Epidemiology and
Infection 2012; 140:1714-20.
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Analyzing and summarizing antimicrobial use prevalence survey data
STEP 1. Describe the prevalence survey – which patients were included, which units, over what
time period was it conducted?
Table 1. Description of the Antimicrobial Use Prevalence Survey
unit(s): _________________
Survey locations:
facility-wide
__________________________
Survey date(s):
Total number of inpatients in
facility/unit(s) surveyed:
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STEP 2. Describe overall antimicrobial use for the unit(s) and time period selected.
Table 2. Antimicrobial Use by Unit
1.
2.
3.
4.
5.
6.
7.
8.
Total
Unit
(list all surveyed)
Number
patients
surveyed
(a)
Number of
patients on
antimicrobials
(b)
% of patients on
antimicrobials
([a/b] * 100)
Table 3. Antimicrobial Use by Week [For use only if prevalence survey was
conducted for a time period > 1 day.]
Number
Number of
patients
patients on
surveyed
antimicrobials
Week
(a)
(b)
1
2
3
4
5
Mean (average) weekly antimicrobial use over the
prevalence survey time period:
% of patients on
antimicrobials
([a/b] * 100)
_____________
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STEP 3. Describe and summarize the data that was collected for the antimicrobial use prevalence
survey. There are multiple ways to summarize the data. The tables below provide a variety of
options for analyzing and summarizing the antimicrobial prevalence survey data. Select summary
tables that are most useful for your facility.
Table 4. Characteristics of Patient that Received Antimicrobials
Characteristic
Number of hospitalized patients that received an
antimicrobial
Male
Number
%
Age group
< 1 month
1-23 months
2-15 years
16-29 years
30-49 years
50-64 years
65-79 years
≥ 80 years
Route of administration
IV
PO
Other
Indication
Infection
Surgical prophylaxis
Medical prophylaxis
Surgical prophylaxis
Single dose
One day
>1 day
Other
Indication documented
Yes
No
Unknown
Infection classification
Community-onset
Hospital-onset
Unknown
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Table 5. Type of Antimicrobials Prescribed
Antimicrobial
No.
%
Amoxicillin-clavulanic acid
Aminoglycosides
Carbapenems
1st gen cephalosporins
2nd gen cephalosporins
3rd gen cephalosporins
4th gen cephalosporins
Cotrimoxazole
Fluoroquinolones
Glycopeptides
Imidazol derivatives
Lincosamides
Macrolides
Nitroimidazol derivatives (oral metronidazole)
Penicillins broad spectrum
Penicillins with B-lactamase inhibitor
Penicillins B-lactamase-sensitive
Penicillins B-lactamase-resistant
Sulfonamides and trimethoprim
Tetracyclines
Other antimicrobials
Total
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Table 6. Antimicrobial Use by Anatomical Site/system
No.
Total
Community-onset
No.
%
%
Hospital-onset
No.
%
Respiratory tract
Skin/soft tissue
Bone/joint
Sepsis
Urinary tract
Gastrointestinal
Ear/nose/throat
Genitourinary system
Cardiovascular system
Central nervous system
Undefined/unknown
Total
Table 7. Antimicrobial Use by Type of Infection
Total
Number of
antimicrobials
%
Community-onset
Number of
antimicrobials
%
Hospital-onset
Number of
antimicrobials
%
Bone & joint infection
Bronchitis
Cardiovascular system
Central nervous system
ENT & eye
Fever of unknown origin/
undifferentiated febrile illness
Gastroenteritis
Gastrointestinal tract - upper &
lower
Genital infection
Liver, biliary tract, & pancreas
Pneumonia
Renal
Sepsis
Skin/soft tissue
Undefined/unknown
Total
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Table 8. Antimicrobial Use by Type of Hospital-onset Infection
Total
number of
diagnoses
% of
diagnoses
Number on
antimicrobials
%
on antimicrobials
Surgical site infection (within 30 days of
procedure)
Device-related (CLABSI, CAUTI, VAP)
C. difficile infection (>3 days after admission or
<30 days following previous admission)
Infection present on admission from a patient
transferred from another hospital
Other hospital-onset infections
Total
CLABSI: central-line associated bloodstream infection
CAUTI: catheter-associated urinary tract infection
VAP: ventilator-associated pneumonia
Table 9. Antimicrobials Prescribed by Specialty
Specialty
Number
antimicrobials
prescribed
Percent of
antimicrobials
prescribed
ICU
Pediatrics
Surgery
Medicine
Geriatrics
Obstetrics/Gynecology
Emergency*
Other
Total
*Only included inpatients
Minnesota Guide to a Comprehensive Antimicrobial Stewardship Program 9/19/2012
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Table 10. Frequency and Resistance Characteristics of Microorganisms Associated
with HAIs
Number of
reports
Percent of
reports
Percent of
patients
surveyed
Staphylococcus aureus
MSSA
MRSA
Clostridium difficile *
Enterobacteriaceae
Enterobacteriaceae, carbapenem and C3G**
susceptible
Enterobacteriaceae, carbapenem and C3G**
resistant
Enterobacteriaceae, C3G** and carbapenem
resistant
Enterobacteriaceae, unknown susceptibility
Enterococcus spp.
Vancomycin susceptible Enterococcus spp.
Vancomycin resistant Enterococcus spp. (VRE)
Enterococcus spp., unknown susceptibility
Pseudomonas aeruginosa
P. aeruginosa, carbapenem susceptible
P. aeruginosa, carbapenem resistant
P. aeruginosa, unknown susceptibility
Klebsiella spp.
K. pneumophila carbapenem susceptible
K. pneumophila carbapenem resistant
K. pneumophila unknown susceptibility
K. oxytoca carbapenem susceptible
K. oxytoca carbapenem resistant
K. oxytoca unknown susceptibility
Acinetobacter spp.
A. baumanni carbapenem susceptible
A. baumanni carbapenem resistant
A. baumanni unknown susceptibility
Other
Total
* All C. difficile diagnostic tests (PCR, EIA, etc)
** C3G:Third generation cephalosporin
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Table 11. Antibiotic Use by Basis for Prescription (microbiological data, clinical data or
prophylaxis) and Unit Type
Medical
ward
Surgical
ward
ICUs
Total
Number of patients
Patients’ median age in months (range)
Number of patients receiving antibiotics
based on microbiological data (%)
Number of patients receiving antibiotics
based on clinical data (%)
Number of patients receiving antibiotics for
prophylaxis (%)
Total number of patients receiving antibiotics
(%)
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