An ideal antimicrobial stewardship team
The list below shows which staff would make up an optimal, real-life team to be involved in the antibiotic prescribing decision for John on the ward round.
- Ward doctor: YES
- Ward nurse: NO
- Pharmacist: YES
- Director of infection prevention and control: NO
- Microbiologist or infectious diseases physician: NO
In an ideal world one might argue that an infection doctor should be involved in the prescribing decision for John. If there is any doubt amongst the clinical team about the most appropriate therapy then an infection doctor should be included.
However, in most organisations, due to limited resources, it may be unrealistic to expect this.
It is also important to remember that John has evidence of severe infection (his blood pressure is low in the context of a systematic inflammatory response) and any delay, due to the seeking of infection advice, in the prescribing and administering of the first dose of antibiotic therapy may impact on his subsequent outcome. Antimicrobial guidelines can play a vital role here. Infection expertise could be sought following the administration of the first dose.
The ward nurse is critically important in administering antibiotic therapy, but in most environments will not be part of the prescribing decision-making team; communication between the prescribing team and the administering nurse team is vital to ensure antibiotic therapy is administered in a timely manner (within 1 hour in severe infection).
There is considerable over-lap in the role of the ward’s doctor and pharmacist in prescribing, but both have specific skill sets and most importantly should work together to come to an optimal prescribing decision.
The role of the pharmacy-doctor team includes:
- Assessing the patient diagnostically and ensuring appropriate infection tests are performed prior to timely antibiotic therapy
- Making an initial prescribing decision that accounts for allergies and pharmaco-kinetic/dynamic factors, including any kidney injury and drug-drug interactions
- Undertaking therapeutic drug monitoring as appropriate
- Deciding on an optimal duration or review date
- Adequate documentation of the prescribing decision
- Monitoring the response to antibiotic therapy and making ongoing prescribing decisions based on response and any positive tests
- Ensuring adherence to local or national guidelines
- Accounting for any prevailing epidemiological issues (such as resistance, as in the scenario).
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