Key Steps in Antimicrobial Stewardship for Clinical Pharmacists
Clinical pharmacists play an essential role in antimicrobial stewardship programs (ASPs) by leading multidisciplinary efforts to optimize antimicrobial use, improve patient outcomes, and combat antimicrobial resistance. 1, 2
Establishing and Participating in a Stewardship Team
Join or establish a formal antimicrobial stewardship committee that includes:
- Clinical pharmacists (ideally with infectious disease training)
- Infectious disease physicians
- Microbiologists
- Emergency department representatives
- Primary care physicians
- Hospital administrators 1
Develop institution-specific antimicrobial guidelines based on:
Core Pharmacist-Led Stewardship Activities
1. Prospective Audit and Feedback
- Review antimicrobial orders daily
- Provide real-time feedback to prescribers on:
- Appropriateness of empiric therapy
- Opportunities for de-escalation
- Dose optimization
- Duration of therapy
- IV to oral conversion 1
2. Formulary Management and Restriction
- Develop and maintain antibiotic formularies
- Implement restrictions for broad-spectrum antibiotics
- Create pre-authorization requirements for selected antimicrobials
- Design antimicrobial order forms with automatic stop orders 1, 2
3. Education and Training
- Conduct active educational programs (seminars, roundtable discussions)
- Provide point-of-care education during clinical rounds
- Develop educational materials on appropriate antimicrobial use
- Train other healthcare providers on antimicrobial stewardship principles 1, 2
4. Clinical Decision Support
- Help implement and optimize electronic clinical decision support systems
- Develop treatment algorithms for common infections
- Create order sets with appropriate empiric therapy options
- Design alerts for inappropriate antimicrobial use 1, 2
Setting-Specific Stewardship Activities
Emergency Department Focus
- Ensure appropriate collection of cultures before antimicrobial initiation
- Guide empiric therapy selection based on local resistance patterns
- Implement rapid diagnostic testing protocols
- Develop protocols for "watchful waiting" when appropriate
- Create systems for follow-up of discharged patients with pending cultures 1
Primary Care/Outpatient Focus
- Implement point-of-care testing (CRP, rapid strep)
- Develop delayed prescribing strategies
- Create patient education materials on appropriate antibiotic use
- Establish follow-up protocols for patients discharged on antibiotics 2, 3
Diagnostic Stewardship
- Guide appropriate use of biomarkers (CRP, procalcitonin)
- Implement and interpret rapid diagnostic tests
- Ensure proper specimen collection before antibiotic administration
- Develop protocols for culture interpretation and reporting 1, 2
Dose Optimization
- Perform pharmacokinetic/pharmacodynamic dosing adjustments
- Consider patient-specific factors (age, weight, organ function)
- Monitor drug levels for appropriate antimicrobials
- Adjust dosing based on site of infection and pathogen characteristics 1
Monitoring and Evaluation
Track key metrics:
Provide regular feedback to prescribers and hospital leadership on stewardship outcomes 1, 2
Common Pitfalls and How to Avoid Them
Pitfall: Focusing solely on restriction without education
- Solution: Pair restriction policies with education on appropriate alternatives
Pitfall: Lack of prescriber buy-in
- Solution: Engage clinical champions from different specialties and demonstrate clinical benefits
Pitfall: Inadequate resources for stewardship activities
- Solution: Start with high-impact interventions and demonstrate cost savings to justify program expansion
Pitfall: Failure to adapt guidelines to local context
- Solution: Regularly update guidelines based on local antibiogram and resistance patterns
Pitfall: Overlooking outpatient antimicrobial use
By implementing these key steps, clinical pharmacists can lead effective antimicrobial stewardship programs that improve patient outcomes, reduce antimicrobial resistance, and optimize healthcare resources.