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Pre and Post Prescription

Flow chart depicting 'pre-authorisation and feedback' and 'prospective audit and feedback' Chung GW et al. Virulence 2013;4(2):151–157

One way to organise the different stewardship strategies into a conceptual framework is to place them into four categories based on two factors:

1) Do they occur before prescribing or after prescribing?

2) Do they require an active or passive interaction with prescribers?

A hybrid approach of active and passive, before and after prescribing methods is likely to have the greatest impact. Please see below for summaries of the most widely used AMS interventions and highlights some pros and cons to each strategy.

Institution-specific treatment guidelines (e.g. skin and soft tissue infections, abdominal infections, pneumonia, surgical prophylaxis)

Institutional guidelines that tailor recommendations from national guidelines to local resistance data, patient population, and formulary.

Classification: Passive pre-prescription

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Provide education

Education provided in large-group format or through written AMS and hospital resources (e.g. policy, newsletters, etc.) to expand clinical providers’ knowledge about antibiotics and infectious diseases

Classification: Passive pre- or post-prescription

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Pre-authorisation

Requirement for providers to seek AMS program or infectious diseases review and approval of antibiotic therapy prior to initiation.

Classification: Active – pre-prescription

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Prospective audit and feedback

AMS program review of patients on select antibiotics after initiation of therapy with directed feedback to the provider.

Classification: Active – pre-prescription

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Clinical pathways and order sets

Syndrome-based guidance for antibiotic selection and diagnostics at the time of order entry.

Classification: Passive – pre-prescription

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Syndrome or culture-based audit and feedback

AMS program review of patients with specific clinical syndromes or positive microbiology culture results with directed feedback to providers.

Classification: Active – pre-prescription

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Rapid diagnostics

Diagnostic technologies which provide rapid identification and/or susceptibility information compared to traditional microbiology methods.

Classification: Active Pre and post prescription

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Allergy initiatives

AMS program led initiatives to improve allergy assessments.

Classification: Active Pre and post prescription

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Dose optimisation protocols

Administration of an antibiotic dose based on patient-specific factors and antibiotic pharmacokinetic/ pharmacodynamics properties.

Classification: Passive Pre and post prescription

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Intravenous to oral conversion

Automatic conversion of intravenous to oral formulations for antibiotics with high oral bioavailability.

Classification: Active post prescription

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Automatic infectious diseases consultations

“Automatic” infectious diseases consultation for eligible patients based on a hospital policy (e.g. those on restricted antibiotics, patients with multi-drug resistant bloodstream infections etc.).

Classification: Active post prescription

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AMS program rounds on high risk units

Target high priority practice areas by performing multidisciplinary patient rounds on a routine basis.

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Antibiotic “time-outs”

Routine procedure for frontline providers to review and document agent choice, dose, duration, microbiology data, and indication.

Classification: Active post prescription

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Automatic stop orders

Use on an antibiotic is permitted for a defined period of time and then requires approval for continuation.

Classification: Active post prescription

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Cascading or tiered antibiotic susceptibility reports

A collaborative effort with microbiology to select specific susceptibility tests to include in clinical culture reports while censoring others.

Classification: Passive post prescription

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Peer comparison data feedback to prescriber

Feedback of antibiotic use and/or appropriateness of prescribing data to the prescriber to allow comparison to other prescribers.

Classification: Active post prescription

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If you are struggling to access the Pro/Con links there is a pdf with all the information in the downloads section below.

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This article is from the free online course:

Antimicrobial Stewardship for the Gulf, Middle East and North Africa

BSAC