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BackgroundThe most recent Infectious Disease Society of America (IDSA) Antimicrobial Stewardship Program Guidelines, published in 2016, suggest the use of strategies to encourage prescribers to assess antibiotic regimens after 48 to 72 hours of therapy. Antibiotic de-escalation, defined as the use of narrower spectrum antibiotics or a discontinuation of antibiotics, has been shown to be safe and is not associated with poorer outcomes. Benefits of de-escalation include improvement in antibiotic resistance profiles, reduction in antibiotic-related adverse events and direct and indirect cost savings.Pharmacists are currently involved with pharmacokinetic dosing of almost all vancomycin orders at Conway Regional. Evidence shows that pharmacist support and interventions can increase physician compliance with guideline recommendations and decrease inappropriate antibiotic use. RequirementsOnly pharmacists that have completed the training as determined by the CRHS Antimicrobial Stewardship Committee are authorized to utilize this policy. Pharmacists must repeat competency annually. ProcedureThe pharmacist responsible for daily review of current vancomycin patients will assess each patient based on the criteria listed below. Upon initial consult if 2 sets of appropriate blood cultures or MRSA nasal screen swab (swab limited to pneumonia only) have not been ordered, the pharmacist may order per protocol under the consulting provider. Blood cultures are to be obtained prior to antibiotics but should not be a reason to delay antibiotics if collection is not feasible. MRSA nasal screen swab can be collected without regard to antibiotic timing as antibiotic treatment has no immediate effect on colonization.After 48 hours of vancomycin therapy and cultures have incubated for 2 days, if a patient meets all of the following inclusion criteria and does not have any exclusion criteria, the pharmacist will contact either the ordering provider or provider assigned to that patient for the day and recommend discontinuation of vancomycin. The standard measurement for antimicrobial stewardship is days of therapy per 1,000 patient days, which will be tracked and reported to appropriate committees. Pharmacist recommendations and provider acceptance rates with be tracked and reported as needed. DocumentationFor all accepted discontinuation recommendations the pharmacist will document that inclusion criteria was met in the note tab of the patient’s EMR.Inclusion Criteria:Blood cultures obtained prior to the start of antibiotics (and urine culture if this is the suspected source of infection.) Age ≥18At least one of the following is true regarding cultures:Definitive blood culture (2 of 2 specimens) for organism that is not MRSA or E.faecalis. Microbiology report states “No growth after” at least 2 or more days for all cultures.Definitive urine culture for organism that is not MRSA or E.faecalis if UTI or pyelonephritis is the only documented suspected infection source. If vancomycin is for empiric treatment of pneumonia, patient must have a negative MRSA nasal screen.Exclusion Criteria: History of MRSA positive culture within past 12 months. Osteomyelitis or Meningitis is suspected and has not been ruled out. Vancomycin monotherapy (if culture negative for MRSA, contact provider for discussion on de-escalation).Bronch or sputum cultures collected within past 48 hours with results still pending.Diabetic foot or diabetic skin/skin structure infection. References: Liu, Peter et al. “Frequency of Empiric Antibiotic de-Escalation in an Acute Care Hospital with an Established Antimicrobial Stewardship Program.”?BMC Infectious Diseases?16 (2016): 751.?PMC. Web. 3 Oct. 2017.Barlam TF, Cosgrove SE, Abbo LM, et al., “Implementing an Antibiotic Stewardship Program: Guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America” Clinical Infectious Diseases; 2016 May 15;62(10):e51-77.Dellinger RD. Guidelines for management of severe sepsis and septic shock: 2012. Critical Care Medicine 2013;41:580. [Accessed 6 September 2016]Dangerfield B, Chung A, Webb B, Seville MT. “Predictive value of methicillin-resistant Staphylococcus aureus (MRSA) nasal swab PCR assay for pneumonia.” Antimicrob Agents Chemother. 2014;58(2):859-64Boyce JM, Pop OF, Abreu-Lanfranco O, et al., “A trial discontinuation of empiric vancomycin therapy in patients with suspected Methicillin Resistant Staphylococcus aureus Health Care-Associated Pneumonia.” Antimicrob. Agents Chemother.March 2013?vol. 57?no 3.?1163-1168 ................
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