Background, Rationale and Suggested Implementation Strategies
General:
- Reduce unnecessarily broad empiric coverage for CAP and UTI
- Utilize safer antibiotic alternatives to Fluoroquinolones for the treatment of CAP and UTI
- Require documentation of dose and indication of antibiotics prescribed in the antibiotic order.
- Encourage documentation of dose, indication, and duration of antibiotics in the progress note.
- Utilize antibiotic time outs after starting antibiotics, including:
- Assess indication(s) for antibiotics
- Review culture results
- Adjust drug selection (de-escalate) and doses
- Consider switching to oral route
- Decide and document treatment duration
- Utilize pharmacists to review cultures, and if positive, ensure that the narrowest, most appropriate antibiotic coverage is chosen for the diagnosis.
- Incorporate the effective duration of therapy into de-escalation protocols (count all days of active therapy including IV).
- When reporting microbiology lab results consider:
- Selective reporting of antibiotic susceptibility results (i.e. suppressing broad spectrum antibiotic susceptibility results when a narrow spectrum antibiotic is effective)
Pneumonia:
- Utilize HMS data to provide audit and feedback directly to providers regarding:
- Coverage of methicillin-resistant Staphylococcus aureus (MRSA) with negative MRSA nasal swabs and/or respiratory cultures
- Coverage of Pseudomonas with negative respiratory cultures
- Encourage de-escalation of vancomycin for pneumonia with negative respiratory cultures and/or nasal swabs for MRSA.
- Educate providers about elimination of HCAP and new broader CAP definition per 2019 ATS/IDSA CAP guidelines
- Educate providers regarding risk factors for multi-drug resistant organisms:
- MRSA Coverage appropriate: respiratory culture in year prior positive for MRSA, blood culture in year prior positive for MRSA, or positive MRSA nasal swan in year prior
- Pseudomonal Gram-negative coverage appropriate: respiratory culture in year prior positive for pseudomonas or other Gram-negative organisms, or blood culture in year prior positive for other Gram-negative organisms
- MRSA Coverage and Pseudomonal Gram-negative coverage appropriate: meets Severe CAP criteria AND previous hospitalization in 90 days prior to hospital encounter AND received IV antibiotics, oral fluoroquinolones, or oral linezolid within 90 days prior to hospital encounter
UTI:
- When reporting microbiology lab results consider:
- Providing treatment recommendations on likely contaminants (e.g., > 3 organisms in a urine culture)