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Bondarenka and Bosso
infrequent to allow a similar analysis. Although the trends do
not indicate dramatic shifting to more oral antifungal therapy,
the ratio remained about 1:1 and indicated that patients were
generally converted to oral therapy if indicated. It was also
shown that when compared with baseline, these conversions
led to a savings of $3710.33 per 1000 patient days over the
duration of the study ($1.8 million adjusted to 2007 dollars).
This was deemed to be an area/effort that should be sustained
and could possibly be improved upon once a formal stewardship program was in place.
Summary of Baseline Evaluation
Areas of opportunity that were identified based on our
assessments described above included a need for a more
structured formulary restriction/review program, IV to PO
conversion program improvements, and the need for more
prospective monitoring of some therapeutic situations and/or
drug use. In addition, other evaluations of our antimicrobial
utilization that are not described in this manuscript revealed
the following needs for optimization: updating of clinical
pathways/order sets and creation of additional ones, de-escalation of therapy, detection and actions on pathogen-drug
mismatches, and evaluation of possible overutilization of
some empiric antimicrobial agents such as piperacillin/tazobactam, and ciprofloxacin for presumed gram-negative
infections. Additionally, development of a formal ASP was
identified as a major area of opportunity as a programmatic
approach to evaluate and implement these identified initiatives. In addition, software programs were considered for
automation of various aspects of surveillance and reporting
functionality to the ASP. It was also recognized that these
preexisting initiatives focused on appropriate drug use/dosing and cost savings rather than quality of care, which is the
main focus and purpose of antimicrobial stewardship. Thus,
a formal stewardship program, focused on assessment and
improvement of patient outcomes through optimization of
antimicrobial use, represented an unmet need.
Step 2: Establishing the Program and
Acquiring Personnel and Resources
The plans for program implementation and the associated personnel needs were incorporated into a business plan proposal
to the hospital's medical director requesting line-item funding
for creation of an AST. The proposal included various initiatives to improve infection- and antimicrobial use-related
patient outcomes as well as projections for potential cost savings. In this plan, we proposed that based on published literature referenced in the IDSA/SHEA Guidelines,12 we could
reduce antibiotic expenditures at our institution by about 20%
which at the time was estimated to yield about $900 000 in
initial annual savings. Additional impacts were expected in a
reduction in length of stay, and hopefully a reduction in microbial resistance which could yield improved patient outcomes
and decreased costs of care for the institution. A list of mechanisms for reduction of costs was also included in the proposal.
Examples of efforts presented were restriction of microbial
use, reduction of treatment duration, dose optimization, development and use of clinical guidelines and pathways, evaluation of current usage and susceptibility patterns to direct future
interventions, and, of course, development of a stewardship
team along with its structure and function.
The original request was for 1.0 full-time equivalent (FTE)
Infectious Diseases trained pharmacy clinical specialist, 1.0
FTE PGY2 Pharmacy Antimicrobial Stewardship pharmacy
resident (a PGY2 Infectious Diseases residency was already
in place), and a pharmacist supervisor (0.1 FTE), along with
0.2 FTE medical director, 0.1 FTE data analyst, and 0.25 FTE
data manager. Not all positions were approved, but in 2009,
the ASP was formally launched with the following funded
positions: 1.0 FTE ID trained pharmacist, 0.25 FTE Medical
Director, and 0.25 co-medical director. Although integrally
involved, clinical microbiology, infection control, and data
management participation was not funded.
Steps 3 and 4: Assess Needs, Select
Initiatives to Implement, and Collect
Outcome Data
At the time of program initiation, a stewardship steering
committee was formed, and was comprised of the Head of
Infection Prevention and Control, the Division Chief of
Infectious Diseases, the Director and Medical Director of
the Clinical Microbiology Lab, and a Clinical Pharmacy
Specialist trained in Infectious Diseases. This committee
advised the core stewardship team about desirable initiatives and data to collect and present to administration for
approval of both concept and resources. The steering committee has since dissolved and is represented in the Antiinfective Subcommittee of the P&T Committee previously
described. The program also maintained the strong working
relationship with the Anti-infective Subcommittee. Among
the first initiatives implemented in 2009 was assessment and
acquisition of a clinical decision support system to assist the
AST in evaluating real-time antimicrobial use. This system
was originally implemented by the Infection Control department, and was later adopted by the Department of Pharmacy
Services including the stewardship pharmacist and the
PGY2 Infectious Diseases (ID) resident. It was used for purposes of stewardship initiatives such as evaluating the daily
use of vancomycin and aminoglycoside dosing, bug-drug
mismatches, organ dysfunction for possible dose adjustments, and utilization of nonformulary antimicrobials.
These reports were monitored daily, and prescribers were
contacted (typically via pager) by the pharmacist to address
concerns with backup from the ID physician on the AST.
Today, the 2 pharmacy clinical specialists who work with
the AST attend daily Technical Rounds in the Clinical
Microbiology Lab where culture results are reported, and
Table of Contents for the Digital Edition of Hospital Pharmacy - July/August 2017
The Evolution of Drug Information Centers and Specialists
Letter: Sodium Phosphates Injection—Osmolarity Labeling Correction
ISMP Adverse Drug Reactions
Drug Monographs: Avelumab and Ribociclib
Formulary Drug Review: Naldemedine
Chimeric Antigen Receptor T-Cell Therapy for Lymphomas: A Review of a Drug Class or Therapeutic Class in a Late Stage of Clinical Development
International Mentoring Programs: Leadership Opportunities to Enhance Worldwide Pharmacy Practice
Compounded Apixaban Suspensions for Enteral Feeding Tubes
Impact of Developing Adult Ketamine Order Panels for the Emergency Department
Critical Appraisal of Biomedical Literature With a Succinct Journal Club Template: The ROOTs Format
Effect of a Rivaroxaban Patient Assistance Kit (R-PAK) for Patients Discharged With Rivaroxaban: A Randomized Controlled Trial
Examining the Use of Sodium Nitroprusside in Coronary Artery Bypass Grafting: Is the Benefit Worth the Cost?
Successful Implementation of an Antimicrobial Stewardship Program at an Academic Medical Center
Hospital Pharmacy - July/August 2017 - 445
Hospital Pharmacy - July/August 2017 - 446
Hospital Pharmacy - July/August 2017 - 447
Hospital Pharmacy - July/August 2017 - 448
Hospital Pharmacy - July/August 2017 - 449
Hospital Pharmacy - July/August 2017 - 450
Hospital Pharmacy - July/August 2017 - 451
Hospital Pharmacy - July/August 2017 - The Evolution of Drug Information Centers and Specialists
Hospital Pharmacy - July/August 2017 - 453
Hospital Pharmacy - July/August 2017 - Letter: Sodium Phosphates Injection—Osmolarity Labeling Correction
Hospital Pharmacy - July/August 2017 - ISMP Adverse Drug Reactions
Hospital Pharmacy - July/August 2017 - 456
Hospital Pharmacy - July/August 2017 - 457
Hospital Pharmacy - July/August 2017 - 458
Hospital Pharmacy - July/August 2017 - Drug Monographs: Avelumab and Ribociclib
Hospital Pharmacy - July/August 2017 - 460
Hospital Pharmacy - July/August 2017 - 461
Hospital Pharmacy - July/August 2017 - 462
Hospital Pharmacy - July/August 2017 - 463
Hospital Pharmacy - July/August 2017 - Formulary Drug Review: Naldemedine
Hospital Pharmacy - July/August 2017 - 465
Hospital Pharmacy - July/August 2017 - 466
Hospital Pharmacy - July/August 2017 - 467
Hospital Pharmacy - July/August 2017 - 468
Hospital Pharmacy - July/August 2017 - Chimeric Antigen Receptor T-Cell Therapy for Lymphomas: A Review of a Drug Class or Therapeutic Class in a Late Stage of Clinical Development
Hospital Pharmacy - July/August 2017 - 470
Hospital Pharmacy - July/August 2017 - International Mentoring Programs: Leadership Opportunities to Enhance Worldwide Pharmacy Practice
Hospital Pharmacy - July/August 2017 - 472
Hospital Pharmacy - July/August 2017 - 473
Hospital Pharmacy - July/August 2017 - 474
Hospital Pharmacy - July/August 2017 - 475
Hospital Pharmacy - July/August 2017 - 476
Hospital Pharmacy - July/August 2017 - 477
Hospital Pharmacy - July/August 2017 - Compounded Apixaban Suspensions for Enteral Feeding Tubes
Hospital Pharmacy - July/August 2017 - 479
Hospital Pharmacy - July/August 2017 - 480
Hospital Pharmacy - July/August 2017 - 481
Hospital Pharmacy - July/August 2017 - 482
Hospital Pharmacy - July/August 2017 - Impact of Developing Adult Ketamine Order Panels for the Emergency Department
Hospital Pharmacy - July/August 2017 - 484
Hospital Pharmacy - July/August 2017 - 485
Hospital Pharmacy - July/August 2017 - 486
Hospital Pharmacy - July/August 2017 - 487
Hospital Pharmacy - July/August 2017 - Critical Appraisal of Biomedical Literature With a Succinct Journal Club Template: The ROOTs Format
Hospital Pharmacy - July/August 2017 - 489
Hospital Pharmacy - July/August 2017 - 490
Hospital Pharmacy - July/August 2017 - 491
Hospital Pharmacy - July/August 2017 - 492
Hospital Pharmacy - July/August 2017 - 493
Hospital Pharmacy - July/August 2017 - 494
Hospital Pharmacy - July/August 2017 - 495
Hospital Pharmacy - July/August 2017 - Effect of a Rivaroxaban Patient Assistance Kit (R-PAK) for Patients Discharged With Rivaroxaban: A Randomized Controlled Trial
Hospital Pharmacy - July/August 2017 - 497
Hospital Pharmacy - July/August 2017 - 498
Hospital Pharmacy - July/August 2017 - 499
Hospital Pharmacy - July/August 2017 - 500
Hospital Pharmacy - July/August 2017 - 501
Hospital Pharmacy - July/August 2017 - Examining the Use of Sodium Nitroprusside in Coronary Artery Bypass Grafting: Is the Benefit Worth the Cost?
Hospital Pharmacy - July/August 2017 - 503
Hospital Pharmacy - July/August 2017 - 504
Hospital Pharmacy - July/August 2017 - 505
Hospital Pharmacy - July/August 2017 - 506
Hospital Pharmacy - July/August 2017 - 507
Hospital Pharmacy - July/August 2017 - Successful Implementation of an Antimicrobial Stewardship Program at an Academic Medical Center
Hospital Pharmacy - July/August 2017 - 509
Hospital Pharmacy - July/August 2017 - 510
Hospital Pharmacy - July/August 2017 - 511
Hospital Pharmacy - July/August 2017 - 512
Hospital Pharmacy - July/August 2017 - 513
Hospital Pharmacy - July/August 2017 - 514
Hospital Pharmacy - July/August 2017 - 515
Hospital Pharmacy - July/August 2017 - 516
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