Team Approach Needed to Curb Inappropriate Prescribing

Marcia Frellick

October 13, 2015

SAN DIEGO — The entire team of infectious disease physicians should be involved in the development of antibiotic stewardship programs to optimize buy-in, expert Gary Kravitz, MD, said here at IDWeek 2015.

Involvement in the approval of guidelines and the decision about which drugs should be restricted will help eliminate divisions between reviewers and reviewees, Dr Kravitz pointed out.

It is important to understand the antibiotic prescribing habits of different physicians and acknowledge their concerns, he emphasized. Some think the guidelines for antibiotics are out of date and don't trust them. Some think that other drugs are inadequate for the complex conditions of their patients. And some are not comfortable with uncertainty and order antibiotics to cover even low levels of uncertainty.

If you have ID physicians in different practices who are wary of each other and suspicious that they are biased in their criticism, then using an ID pharmacist to run your stewardship program is "an outstanding idea," Dr Kravitz said.

At the University of Alabama at Birmingham Hospital, the stewardship program, which is led by an ID physician, "runs 24 hours a day, 7 days a week," said Danielle Kunz, RPh, an ID and antimicrobial stewardship program pharmacist at the hospital.

Physicians and Pharmacists

The program started in 2007, and the committee that runs it, which reports to the quality and safety division of the hospital, consists of the lead ID physician, three other ID physicians, three non-ID physicians, and the ID pharmacist.

The University of Alabama has 120 pharmacists in a decentralized practice who are out on the units. "They have made antimicrobial stewardship part of their everyday function in taking care of patients," Kunz told Medscape Medical News.

The pharmacists round with the care teams. They're looking at pharmacokinetic dosing and medication reconciliation, and working on the front lines with stewardship, she explained.

 
Give them what they need to manage conflict.
 

"Instead of me, as an ID pharmacist, running reports every morning and calling physicians, saying, 'You need to change this antibiotic,' the pharmacists are doing that and I'm coordinating with them," she said.

Training the pharmacists already in place, rather than hiring more ID pharmacists, has helped extend resources, she pointed out. This is also practical because there is not enough time or programs to get pharmacists trained to do stewardship by the time federal mandates kick in 2017, she added.

Hospitals will have to learn to use nurses, house staff, and pharmacists under the coordination of a stewardship program to actually improve antibiotic use, she said. But training and support for pharmacists is essential, she pointed out.

"Give them what they need to manage conflict," Kunz explained. "You're going to make them extremely unpopular with their service when they start trying to restrict certain antibiotics physicians are asking for."

At the University of Alabama, it is the ID physicians who give final approval when a non-ID physician wants to use a restricted drug. "That lets the ID physician do physician-to-physician education," she said.

Within the program, it is recognized that conditions change and that antibiotics can become necessary for a patient.

However, to eliminate requests by physicians who ask for restricted drugs after hours, the university has a policy that pharmacists can authorize one or two doses, but the physician has to call the ID physician the next morning for further approval.

"We don't want to restrict antibiotic use to the point of patient harm," Kunz explained.

Dr Kravitz and Ms Kunz have disclosed no relevant financial relationships.

IDWeek 2015. October 11, 2015.

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