Antimicrobial Stewardship Teams and the Microbiology Lab: An Essential Collaboration

Briefly describe your daily role as an antimicrobial stewardship pharmacist.

The main role I perform daily as an antimicrobial stewardship pharmacist is ensuring patient safety.  I use the term “patient safety” because it is a broad concept that everyone can understand and is generally relatable. One of the duties of the antimicrobial stewardship pharmacists is to perform prospective audit and feedback on a variety of antimicrobials.  Our prospective audits target antimicrobial use based on duration of therapy, spectrum of activity, therapy duplication, and potential for de-escalation or escalation. In addition to evaluating patients based on what antimicrobials are being used, we also identify and evaluate patient therapies based on infecting organism resistance patterns (e.g., ESBL, CRE, VISA), source of infection (bacteremia), and specific microorganisms (i.e. Pseudomonas aeruginosa and Acinetobacter baumannii) regardless of the source.

In addition to clinical work, my remaining time is split between quality improvement projects, teaching students on clinical clerkships, attending various local and regional meetings that involve a process or formulary changes, and responding to infectious disease-related drug information inquiries/issues.

What are some ways your stewardship team has collaborated with the microbiology lab to optimize antibiotic use?

The supervisor of microbiology is part of the antimicrobial stewardship team and attends all of the stewardship meetings.  Partnering with the microbiology lab has helped improve antibiotic utilization. Together we developed and implemented a computerized urinalysis and urine culture order-set that consisted of a urinalysis with reflex to microscopy.  Essentially, if the urinalysis was not indicative of a urinary tract infection, a urine culture would not be performed.  This process paired with prospective audit & feedback helped reduce the rate of antibiotic use for asymptomatic bacteriuria. The microbiology lab is also instrumental in more rapidly escalating individualized therapy changes by implementing reflex susceptibility testing for multidrug-resistant organism such as Pseudomonas aeruginosa.  Setting up additional susceptibility testing would reduce the gap in time between the clinician seeing the results and ordering the same test later that day.  The microbiology lab is also instrumental in providing data needed to build and trend the annual antibiogram. Using susceptibility data, we were able to remove levofloxacin from the sepsis protocol and replaced it with more effective therapy options.

My personal favorite collaboration with microbiology lab was the evaluation of rapid diagnostic systems in bacteremia. We evaluated a new technology for gram-negative bacteremia that uses fluorescence in situ hybridization to identify the organism and morphokinetic cellular analysis to determine antimicrobial susceptibility within 8 hours of the positive blood culture.  We compared the use of this new technology with the previous rapid test that only identified the organism and resistance markers within 2.5 hours.  The hypothesis being evaluated was whether attaining specific antibiotic susceptibility data earlier would be associated with changes in antimicrobial use, decrease in hospitalization status-post positive bacteremia culture, or mortality benefits. The answer was yes to all of the above.

What does the future hold for stewardship and microbiology lab collaboration?

I think the bond between microbiology and stewardship will only increase over time.  Rapid diagnostic tools will evolve over time to provide more accurate and faster results. Based on published literature, pairing the combination of rapid diagnostic tools with someone on the other end to act upon the results will lead to better outcomes.

What does "Being Antibiotics Aware" mean to you?

When I think about “Being Antibiotics Aware,” I think about how antibiotics are life-saving medications. It is one of the reasons why life spans are as long as they are. But I also think of antibiotics as a finite resource with a shortened half-life.  “Being Antibiotic Aware” means, yes to antibiotic therapy in patients with infections, but therapy should be re-evaluated for narrower options and shorter durations when possible. Antibiotics are effective medications, everyone’s goal should be to ensure that 10 or 20 years from now, they remain effective.

What is one pearl you have for all pharmacists to help them be antibiotic stewards?

One of the things I think about everyday as a stewardship pharmacist is patient first. My goal is to make sure that patients are on the most appropriate antibiotic regimen.  Our medical and nursing colleagues are likely thinking the same thing on daily basis when they show up for work, “how can I help patients.” When antibiotics are prescribed, the intent is to treat an infection. No one shows up to work with the intent of creating pan-resistant organisms. I don’t take it personally when prescribers don’t want to de-escalate or stop therapy.  My job is to open the dialogue and inquire if the current therapy is the best therapy for the patient. At times, some agents are not needed and other times escalation in therapy is warranted. My one pearl for all pharmacists, is that antibiotics are not being used out of malice, but concern over the patient. Our duty is to ask the hard questions regarding antibiotic need, selection, dose, duration, and route to limit the risk of an adverse event or the creation of a multidrug-resistant organism.

Lee Nguyen, PharmD, BCPS (AQ ID), BCIDP

Health Sciences Associate Clinical Professor and Antimicrobial Stewardship Pharmacist

Department of Clinical Pharmacy Practice, School of Pharmacy, University of California-Irvine, Irvine, CA