Infection Control & Hospital Epidemiology
Table 5. Recommended physician-, pharmacist- and microbiology-driven AMS program interventions. Intervention
Strength of recommendation
Physician-driven
Implementation of local guidelines for surgical prophylaxis and empiric antibiotic therapy of common infection syndromes
Use of monotherapy instead of combination antibiotics as a standard approach to most infection treatments
Use of antibiotic diversity (e.g. multiple agents and classes)
Formulary restriction and preauthorization and/or prospective audit and feedback
Education
Pharmacist-driven De-escalation
Dose optimization (using PK/PD models and therapeutic drug monitoring)
IV to oral switching Microbiology-driven
Use of rapid diagnostic testing in addition to conventional diagnostic testing
Selective antibiotic susceptibility reporting
Site-specific hospital antibiograms with or without active surveillance
Strong Strong
Strong Strong
Weak Low High Low Moderate Low
China,65,73 Hong Kong,75 Indonesia,22 Singapore38,39
China76 Japan77,78
China,79 Hong Kong,80 Malaysia,10 Singapore,39,54,48,62 Korea,64 Thailand33,55
China,81 Japan,82 Korea,56 Taiwan,83 Thailand,55 Singapore54,57
Strong Strong
Strong Strong
Strong Strong
AMS, antimicrobial stewardship; IV, intravenous; NA, not available; PK/PD, pharmacokinetic/pharmacodynamic
specific drugs increases when consumption of those drugs passes a critical threshold.50,51 Therefore, strategies promoting antibiotic diversity should be encouraged, such as changing the first-line antibiotic in consecutive patients or prescribing according to patient characteristics.52,53 In line with IDSA/SHEA guidelines,8 we do not recommend antibiotic cycling as an AMS strategy.
Formulary restriction and preauthorization and/or prospective audit and feedback (strong recommendation, moderate-quality evidence). All AMS programs should include some form of pro- spective audit and/or formulary restriction. With restriction and preauthorization, approval of restricted agents must be granted by an ID expert or another authorized clinician (eg, if ID specialists are unavailable) before they can be prescribed. With prospective audit and feedback, which has similar effects to formulary restriction and preauthorization, the prescription is reviewed by appropriate staff members after empiric antibiotic therapy has been initiated, and recommendations are made based on factors such as hospital guidelines, potential for misuse (spectrum of antibiotic activity), hospital AMR patterns, and the availability of microbiologic test results. Many physicians in Asian countries practice social bedside medicine and like to be personally involved in patient care, so prospective audit and feedback is better suited to such prescribing culture than preauthorization.27,54,55 Formulary restriction and preauthorization can be conducted
on a small scale by evaluating antimicrobial usage patterns and resistance trends, then devising interventions targeted at a single
antibiotic agent or class thought to be misused. For example, an intervention focused on carbapenems in response to endemic carbapenem-resistant A. baumannii may be more practical than wide-ranging formulary restriction in many Asian hospitals.
Education (weak recommendation, low-quality evidence). Passive educational activities, such as quarterly or yearly lectures, should not be solely relied upon to improve antibiotic prescribing, but they should be used to complement other AMS activities. Presenting the positive impact of the hospital AMS program can encourage participation by all providers. An education program in combination with ongoing feedback as part of the audit/feed- back process is an example of an inexpensive and highly effective AMS program that could be easily applied to many hospitals and is well suited to the Asian bedside prescribing culture.54–57
Recommended pharmacist-driven interventions
De-escalation (strong recommendation, low-quality evidence). With this approach, once the pathogen and its susceptibility are known, empiric prescribing should be changed to a narrow- spectrum, pathogen-directed treatment as soon as possible. Carbapenem de-escalation is an example of a beneficial strategy in settings of endemic gram-negative resistance and high rates of carbapenem prescription often found in Asian hospitals.58 Choice of antibiotics for de-escalation during empirical therapy should be based on hospital guidelines, while that for pathogen-
Low Low to moderate Moderate Moderate
Low Low
Thailand,84 Singapore58 Singapore54,58
Korea,85 Singapore38 Australia86 NA Singapore38,57
1241
Overall evidence quality8,17,18
Relevant studies from the Asia-Pacific region
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