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Be Antibiotics Aware

Avoid Duplicate Anaerobic Coverage

U.S. Antibiotic Awareness Week is November 18th-24th. During this observance, SIDP is highlighting members who promote optimal antibiotic use and combat the threat of antibiotic resistance in impactful and innovative ways. This blog features Dr. Ryan W. Stevens and his antimicrobial stewardship program's initiative to avoid duplicate anaerobic coverage. Learn more from the CDC about avoiding duplicate anaerobic coverage here

Briefly describe how your antimicrobial stewardship program avoids duplicate anaerobic coverage and why this is important for patient care. 

I recently transitioned from a 400-bed tertiary care center in Anchorage, AK to an academic medical center in Rochester, MN. At my previous facility the antimicrobial stewardship program (ASP) performed prospective audit with intervention and feedback to address orders for duplicate anaerobic therapy. A patient scoring report built into our electronic medical record identified any patient receiving metronidazole and any other anti-anaerobic antimicrobial. The team then educated the decentralized pharmacist and physicians seeing the patient about the potential harms of the combination and lack of clinical benefit (in most scenarios). We often piggybacked this recommendation with the opportunity for de-escalation of the empiric regimen in patients with mild/moderate, community-acquired intra-abdominal infections who were receiving unnecessarily broad empiric therapy. A similar alert and interventional model was implemented to identified patients in which clindamycin was being utilized in combination with other anti-anaerobic therapies. Here at my new institution, the antimicrobial stewardship team, led by Lynn Estes, PharmD and Dr. Aaron Tande, has been doing amazing work for many years! Despite being a much larger facility, a similar approach to avoiding duplicate anaerobic coverage has been deployed with similar favorable results. Due to effective feedback from the ASP over a period of time, providers and pharmacists often address this issue now before it reaches the stewardship team’s radar!

How do you educate all hospital pharmacists on avoiding duplicate anaerobic coverage?

I believe this is best accomplished in two steps. First, some may lack knowledge about which antimicrobial agents have anaerobic coverage included in their typical spectrum of activity; and education should be focused on all agents with anaerobic activity and which organisms those agents effectively treat. Second, once pharmacists are aware of the spectrum of anaerobic activity of certain agents, the next step is to define situations in which duplicate anaerobic therapy may be appropriate. It is easier for front line pharmacists to screen patients receiving duplicate anaerobic coverage for the handful of scenarios where it may be appropriate, instead of screening for the many situations in which it is inappropriate. Outside of these limited scenarios, pharmacists should be skeptical when duplicate anaerobic coverage is encountered and attempts to streamline antibiotic selection should be pursued. Education on anti-anaerobic agents and exceptions of appropriate use are simple steps to educate all hospital pharmacists on how they can avoid duplicate anaerobic coverage.

What does "Being Antibiotics Aware" mean to you?

Antibiotic awareness comes back to a pivotal recognition of how infectious diseases pharmacotherapy differs from pharmacotherapy in every other area of medicine. A cardiologist does not have to fear that using metoprolol may decrease the future effectiveness of carvedilol, but these are the realities of antimicrobial administration—the more we use the agents available to us, the less likely they are to work in the future. This may apply to a single patient who is exposed to an antimicrobial and develops a multidrug-resistant infection in the future, or on a larger scale, where increasing utilization of a certain antibiotic decreases the empiric effectiveness of the agent in the future for individuals in that population. On both patient and population health levels, our decisions around the use of antimicrobials carry weight and are accompanied by consequences. Within the context of antimicrobial prescribing, the premise to “first do no harm” must equally consider the potential risk of withholding or under-treating an infection versus that of exposing patients to undesirable, unintended effects of antimicrobials and failing to steward this valuable resource. The situation is complicated by decades of lack of stewardship, propagation of antimicrobial myths, and the general perspective that antimicrobials, as a resource, are both bottomless and harmless. Slowly but surely, the United States is working to reverse this pattern as we develop institutional, long-term care, and outpatient antimicrobial stewardship programs, educate patients and providers, gather and disseminate data, and encourage the development of new antimicrobials. All this considered, we cannot overlook the reality that amongst the herculean framework of “big stewardship” are many practicing professionals, each one of which is in need of awareness that their day-to-day decisions matter and carry weight for every patient seen, prescription written, and antimicrobial dispensed. Being antibiotic aware means that one must approach each antibiotic order purposefully and intentionally with the goal of both maximizing patient outcome and minimizing the unintended adverse events of antimicrobial use.

What is another way all pharmacists can Be Antibiotics Aware?

I often tell learners on rotation to consider implementing a checklist incorporating the 5 D’s of antimicrobial stewardship into their everyday practice, regardless of their eventual work location or specialty. Each time an antibiotic order is reviewed, we should all be considering if we have determined the correct diagnosis, drug, dose, duration, and if we can de-escalate. Every pharmacist, not just those with infectious diseases training, can apply this principle to their review of antibiotic orders in order to incorporate antimicrobial stewardship practices into their day-to-day activities in a tangible way. This level of scrutiny on multiple levels of care throughout the patient’s stay would assure that antimicrobial therapy is being optimized at each opportunity for improvement and at the critical transitions of care. Antibiotic awareness is not the job of one pharmacist or a small team of pharmacists running an antimicrobial stewardship program; it is the responsibility of every pharmacist in the profession who encounters patients on antimicrobials.

Ryan W. Stevens, PharmD, BCPS, BCIDP

Infectious Diseases/Antimicrobial Stewardship Pharmacist

Mayo Clinic, Rochester, MN

PharmD, University of Montana

PGY1 Residency, Alaska Native Medical Center, Anchorage, AK

MAD-ID Advanced Antimicrobial Stewardship Certificate

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