Table 2.
Examples of Common ASP Interventions Resulting From Interdisciplinary Microbiology Plate Rounds and Their Potential Clinical Impact
| Category | Intervention or Examples | Potential Clinical Impact |
|---|---|---|
| Antibiotic allergy | • Identification of penicillin allergic patients prompts earlier in vitro susceptibility testing of alternative agents | • Faster in vitro susceptibility data • Avoid delay in time to appropriate therapy |
| Antimicrobial resistance markers | • Methicillin-resistant vs methicillin sensitive Staphylococcus aureus (PCR, PBP2a, chromogenic agar) • Vancomycin-resistance in Enterococcus spp (PCR) • KPC-producing organisms (in facilities where these are uncommon) |
• Shorter time to effective and/or optimal therapy • Cost savings (supplement to anti-MRSA pneumonia therapy duration of treatment limits) |
| Bug-drug mismatch from emergency department or outpatient clinics | • Alert provider to untreated pathogens (yeast, S aureus, GNR) from critical sterile sites (blood, CSF, etc) • Alert provider to discordant result • Suggest alternative agents |
• Decrease time to appropriate therapy • Prevent unnecessary hospitalization • Avoid IV/IM administration or PICC insertion (eg, fosfomycin for MDR cystitis) |
| Clarification of improper specimen/culture ordering | • Endotracheal specimen ordered as a BAL or vice versa • Abdominal abscess ordered as abdominal fluid • CF culture in non-CF patient |
• Decrease unnecessary/excessive microbiology workup |
| Clinical liaison services | • Reporting organism in mixed urine culture of patients with bacteremic urosepsis • Review prior patient history, cultures from OSH |
• Established source of bacteremia allows for conversion to oral therapy in some situations • Modification of therapy and/or microbiologic workup based on previous culture and susceptibility results |
| Infection vs colonization | • Assist with assessment of clinical presentation and clinical correlation for lower respiratory cultures and urine cultures, etc | • Avoid unnecessary antimicrobial utilization • Decrease unnecessary/excessive microbiology workup |
| MDR organisms | • Earlier in vitro susceptibility testing of alternative/salvage antimicrobials (tigecycline, polymyxins) • Earlier involvement of infectious diseases consultant |
• Decrease delay in time to approriate therapy • Improve patient outcomes |
| Mixed cultures | • Predominance vs polymicrobial • Liaison service between provider and microbiologists to determine extent of work up of mixed cultures in a more timely fashion • Requirements for in vitro susceptibility testing for all isolates vs selective isolates |
• May prevent unnecessary escalation of antibiotic treatment and may decrease time to appropriate therapy • Avoid unnecessary/excessive microbiology workup • Streamlining of antimicrobial regimen for polymicrobial infection |
| Optimal dose selection | • Actual MIC for a given antimicrobial agent | • Optimize the therapeutic regimen based on pharmacokinetic and pharmacodynamic principles |
| Rapid diagnostics (PCR, MALDI-TOF)* | • Create clinical pathways to increase utilization of results | • Shorter time to effective and/or optimal therapy • Decrease broad-spectrum antimicrobial utilization |
| Reporting* | • Avoid inappropriate/suboptimal in vitro susceptibility results for site specific cultures (early-generation cephalosporins for inducible AmpC beta-lactamase-producing Gram-negative bacilli in blood cultures) | • Decrease inappropriate prescribing, therapeutic failures, and metastatic infections • Increase appropriate antimicrobial selection |
Abbreviations: ASP, antimicrobial stewardship program; BAL, bronchoalveolar lavage; CF, cystic fibrosis; CSF, cerebrospinal fluid; GNR, Gram-negative rod; IDSA, Infectious Diseases Society of America; IM, intramuscular; IV, intravenous; KPC, Klebsiella pneumoniae carbapenemases; MALDI-TOF, matrix-assisted laser desorption ionization time-of-flight; MDR, multidrug resistant; MIC, minimum inhibitory concentration; MRSA, methicillin-resistant Staphylococcus aureus; OSH, outside hosptial; PBP2a, penicillin binding protein 2A; PCR, polymerase chain reaction; PICC, peripherally inserted central venous catheter.
*IDSA/SHEA Stewardship Guideline recommended.