Table 51-18.

Recommendations for Developing an Institutional Program to Enhance Antimicrobial Stewardship

Recommendation	Level of Evidence
▪Create a multidisciplinary antimicrobial stewardship team, including an infectious disease physician and a clnical pharmacist with infectious disease training	A-II
▪Include, if possible, a clinical microbiologist, an information systems specialist, an infection control professional, and hospital epidemiologist	A-III
▪Foster collaboration between the antimicrobial stewardship team and the hospital infection control committee	A-III
▪Create a climate of support and collaboration between the antimicrobial stewardship team and the hospital administration and medical staff leadership	A-III
▪Develop infrastructure to measure antimicrobial use and track use on ongoing basis	A-II
▪Employ a system of prospective audit of antimicrobial use with direct interaction and feedback to the prescriber by an infectious disease physician or a clinical pharmacist with infectious disease training	A-I
▪Use formulary restrictions and preauthorization requirement to reduce antimicrobial use and cost	A-II
▪Provide education to health care providers regarding stewardship strategies	A-III
▪Education must be combined with active interventions to improve antimicrobial prescribing practices	B-II
▪Develop evidence-based multidisciplinary guidelines incorporating local microbiology and resistance patterns to improve antimicrobial utilization	A-I
▪No recommendation can be made regarding antimicrobial cycling as a means of preventing or reducing antimicrobial resistance	C-II
▪Use antimicrobial order forms as a component of antimicrobial stewardship	B-II
▪No recommendation can be made regarding the routine use of combination therapy to prevent emergence of resistance	C-II
▪Streamline or de-escalate antimicrobial therapy on the basis of culture results	A-II
▪Optimize antimicrobial dosing on the basis of individual patient characteristics, causative organisms, site of infection, and pharmacokinetic and pharmacodynamic characteristics of the drug	A-II
▪Use health care information technology such as electronic medical records, computerized physician order entry and clinical decision support to improve antimicrobial prescribing	B-II
▪Use computer-based surveillance for more efficient targeting of antimicrobial interventions, tracking of resistance patterns, identification of nosocomial infections and adverse drug reactions	B-II
▪Engage the clinical microbiology laboratory to participate in antimicrobial stewardship by providing patient-specific culture and susceptibility data and by assisting infection control efforts in the surveillance of resistant organisms and in the molecular epidemiologic investigation of outbreaks	A-III
▪Determine the impact of antimicrobial stewardship by measuring process and outcomes	B-III

Based on the Infectious Diseases Society of America grading system for ranking recommendations in clinical guidelines. A, good evidence to support a recommendation for use; B, moderate evidence to support a recommendation for use; C, poor evidence to support a recommendation for use; I, evidence from >1 properly randomized, controlled trial; II, evidence from >1 well-designed clinical trial, without randomization; from cohort or case-controlled analytic studies; from multiple time-series; III, evidence from expert opinion.

Modified from Dellit TH, Owens RC, McGowan JE Jr, et al: Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clin Infect Dis 2007;44:159-177.

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