Transcript ANTIMICROBIAL STEWARDSHIP IN THE COMMUNITY HOSPITAL

ANTIMICROBIAL STEWARDSHIP IN
THE COMMUNITY HOSPITAL
Practical Tools and Techniques for Implementation
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ANTIMICROBIAL STEWARDSHIP
IN THE COMMUNITY HOSPITAL
PRACTICAL TOOLS & TECHNIQUES
FOR IMPLEMENTATION
CME Information
Jointly sponsored by:
The University of Cincinnati, Potomac Center for
Medical Education, and Rockpointe Corporation
Co-organized with presenting partner:
The Society for Healthcare Epidemiology of America
Supported by an educational grant from:
• Astellas Global Development, Inc.
• Cubist Pharmaceuticals, Inc.
• Pfizer, Inc.
Steering Committee Disclosures
• Stephen Parodi, MD: Nothing to Disclose
• Maureen K. Bolon, MD, MS: Nothing to Disclose
• Elizabeth S. Dodds Ashley, PharmD, MHS, BCPS:
Nothing to Disclose
Faculty Disclosures
The faculty reported the following relevant financial relationships that
they or their spouse/partner have with commercial interests:
TO BE FILLED IN BY
PRESENTING
• Presenting
Physician,
PHYSICIAN
MD
Category – Disclosures
Planner and Manager Disclosures
Non-faculty content contributors and/or reviewers reported the
following relevant financial relationships that they or their
spouse/partner have with commercial interests:
University of Cincinnati, Potomac Center for Medical
Education, and Rockpointe Corporation staff involved with
this activity have nothing to disclose.
Educational Objectives
At the conclusion of this activity, participants should be able to:
• Evaluate the principles and objectives of an antimicrobial
stewardship program
• Identify the barriers to implementing a successful
stewardship program in a community hospital
• Discuss antimicrobial stewardship strategies that can be
implemented effectively in a community hospital
• Integrate evidence-based practices and resources to improve
antimicrobial use
• Facilitate interaction with the medical staff at the health care
facility to promote acceptance of a stewardship program
Case for Antimicrobial Stewardship
Programs (ASP)
• 30% of hospital pharmacy budgets due to ABX
• 50% of ABX use estimated to be inappropriate
• Resistant organisms develop 2º inappropriate use
– MDRO infections have  morbidity and mortality
– MDROs have  costs (LOS, tx failures)
• Evidence shows ASP can improve:
– Individual patient outcomes
– Decrease resistance patterns
– Decrease Clostridium difficile infection
– Decreases costs of care
Dellit TH, et al. Clin Infect Dis. 2007;44(2):159-177.
Valiquette L. Clin Infect Dis. 2007;45(suppl 2):S112-S121.
Utilization and Resistance
Albrich WC, et al. Emerg Infect Dis 2004;10:514-7
ESKAPE
•
•
•
•
•
•
Enterobacter
S aureus
Klebsiella (KPC) (NDM-1)
Acinetobacter
P aeruginosa
Enterococcus /ESBL
KPC=K pneumoniae carbapenemases; ESBL=extended-spectrum β-lactamase.
Geographical Distribution of
KPC-Producers
Sporadic isolate(s)
2001
Centers for Disease Control and Prevention.
Geographical Distribution of
KPC-Producers
Widespread
Sporadic isolate(s)
November 2006
Centers for Disease Control and Prevention.
Geographical Distribution of
KPC-Producers
Sporadic and
Widespread isolate(s)
2010
Centers for Disease Control and Prevention.
We are
here
Then
Now
Resistance
New Antimicrobials
Antibiotic Armageddon
Incidence and Mortality of CDI
Are Increasing in the United States
Principal diagnosis
All diagnoses
Mortality
80
60
50
40
30
20
20
15
10
Annual CD-related Mortality Rate
per Million Population
70
25
No. of CDI Cases per 10,000 Discharges
90
5
10
0
0
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
Elixhauser A, Jhung M. Healthcare Cost and Utilization Project. Statistical Brief #50.
http://www.hcup-us.ahrq.gov/reports/statbriefs/sb50.pdf. Published April 2008. Accessed March 10, 2010.
Redelings MD, Sorvillo F, Mascola L. Increase in clostridium difficile–related mortality rates, United States,
1999–2004. http://www.cdc.gov/EID/content/13/9/1417.htm. Published September 2007. Accessed March 10, 2010.
ASP Goals
•
•
•
•
•
•
•
Prevent or slow emergence of ABX resistance
Optimize selection, dose, duration of Tx
Reduce adverse drug events
Reduce secondary infection (eg. CDI, MDROs)
Reduce morbidity and mortality
Reduce length of stay
Reduce health care expenditure
MacDougall C, Polk RE. Clin Microbiol Rev. 2005;18(4):638-656;
Ohl CA. J Hosp Med. 2011; 6(Suppl 1): S4-15;
Dellit TH, et al. Clin Infect Dis. 2007;44(2):159-177.
Can Antimicrobial Stewardship Limit
the Emergence of Resistance?
• Best evidence for:
– Decreased resistant Gram-negative bacilli1,5
– Decreased CDI1-4
– Decreased VRE1
1. Carling P, et al. Infect Control Hosp Epidemiol. 2003;24(9):699-706.
2. Climo MW, et al. Ann Intern Med. 1998;128(12, pt 1):989-995.
3. Pear SM, et al. Ann Intern Med. 1994;120(4):272-277.
4. McNulty C, et al. J Antimicrob Chemother. 1997;40(5):707-711.
5. de Man P, et al. Lancet. 2000;355(9208):973-978.
Impact of Antimicrobial Formulary Interventions
on ESBL E coli and Klebsiella Species
ESBL-EK=extended-spectrum β-lactamase-producing Escherichia coli and Klebsiella species.
Reprinted with permission from Lipworth AD, et al. Infect Control Hosp Epidemiol. 2006;27(3):279-286.
©The University of Chicago Press. http://www.press.uchicago.edu.
ASP Can Make a Difference with HA-CDI
Tertiary Care Hospital; Québec, Canada (2003-2006)
CDAD=C difficile-associated diarrhea; Abx=antibiotics.
Reprinted with permission from Valiquette L, et al. Clin Infect Dis. 2007;45(suppl 2):S112-S121.
©The University of Chicago Press. http://www.press.uchicago.edu .
ASP Can Improve Individual Patient Clinical
Outcomes
100
AMP
UP
Percentage
80
60
40
20
0
Appropriate
RR 2.8 (95% CI 2.1-3.8)
Cure
Failure
RR 1.7 (95% CI 1.3-2.1)
RR 0.2 (95% CI 0.1-0.4)
AMP=antibiotic management program; UP=usual practice; RR=relative risk; CI=confidence interval.
Fishman N. Am J Med. 2006;119(6 suppl 1):S53-S61.
Patients at Risk for MRSA Treated Appropriately
Pre- and Postdecision Support Tool Intervention
Patients at Risk for Pneumonia aeruginosa Treated
Appropriately Pre- and Postdecision Support Tool
Intervention
Percent
Percent
ASP Can Improve Individual Patient Clinical
Outcomes
Preintervention
Postintervention
MRSA=methicillin-resistant Staphylococcus aureus; Tx=treatment.
Deschambeault AL, et al. Abstract presented at: 46th Annual Meeting of the Infectious
Diseases Society of America; October 2009; Philadelphia, PA.
Economic Outcomes
Randomized Controlled Trial
Cost
Antibiotics
Infectionassociated costs
Total costs
*95%
AMP
(median)
$53
$172
UP
(median)
$95
$246
Difference
(95% CI)*
$42 ($-3, $103)
$74 ($-40, $197)
$10,021
$10,615
$594 ($-4510, $5331)
CI (bias corrected) calculated by bootstrapping around the medians.
Annual savings (600 interventions/month)
Antibiotics
$302,400
Infection-associated costs
$533,000
Total costs
> $4,250,000
Fishman N. Am J Med. 2006;119(6 suppl 1):S53-S61.
Total Antibiotic Expenditures
MHH 1995-2003
4
$18.00
Dollars (millions)
3.5
$16.00
ASP Active
3
$14.00
2.5
$12.00
2
1.5
$10.00
1995
1996
1997
1998
Total antiinfective-dollars
1999
2000
2001
2002
2003
Total antiinfective-dollars/patient day
Mohr JF et al. 44th ICAAC. Abstract #987. November, 2004.
Antimicrobial Stewardship
The Cost of Discontinuing a Program
• Large tertiary care academic medical center: ASP Active 2002-2009
• FY01-08: ABX Utilization cost savings > $14 million
• FY09: Discontinued ASP = CONSEQUENCES
– >$1 million ABX costs FY09 compared with FY08
– 33-147% increased cost of broad spectrum agents
– Overall DDD increased 4.8% AND broad spectrum DDD increased 26.8%
• Conclusions:
– ASP is a long term proposition
– The lack of ASP has significant costs
Standiford H, et al. Abstract presented at: Fifth Decennial International Conference
on Healthcare-Associated Infections; 2010; Atlanta, GA. Abstract 666.
Key Elements for Successful ASP
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Establish compelling need and goals for ASP
Senior leadership support
Effective local physician champion
Adequate resources (pharmacy, infection preventionist [IP],
microbiology, information technology [IT])
• Primary objectives: optimize clinical outcomes and reduce
adverse events, not reduce costs
• Good teamwork
• Agreed upon process and outcome measures
Guidelines
Domestic and International
• IDSA/SHEA Guidelines1 suggest:
– Physician and pharmacist compensated for time
• Guidelines for Antimicrobial Stewardship in Hospitals in Ireland2
– Smaller hospitals should have at least one pharmacist with part-time
responsibilities
– Regional committees should be set up to serve smaller hospitals or
develop regional guidelines
• European Union Project Antibiotic Stewardship International3
– An antibiotic officer is needed

For smaller hospitals, individual could be either physician, pharmacist, or
trained microbiologist
IDSA =Infectious Disease Society of America; SHEA=Society for
Healthcare Epidemiology of America.
1. Dellit TH, et al. Clin Infect Dis. 2007;44(2):159-177; 2. Health Protection
Surveillance Centre. http://www.hpsc.ie. Accessed September 29, 2010;
3. Allerberger F, et al. Chemotherapy. 2008;54(4):260-267.
Physician Champion
• Basic knowledge of antibiotics*
• Must show interest in taking a leadership role in the local
community
• Respected by his or her peers
• Good interpersonal skills
• Good team player
• Basic understanding of human factors and culture
transformation
*Does not need to be an infectious disease specialist.
Collaboration and Role of the Pharmacist
Continuation, Advancement of Knowledge…1990s-Current
Clinical pharmacists
Clinical
pharmacist
and ID
physician
Research
Patients
Focus on patient
safety (randomized
trial)
Antimicrobial Stewardship Program
ASP
Operationalize
Antibiotic Stewardship Activities
• Restrictive formulary
• Generic substitution
• Therapeutic substitution
• Restricted use of formulary compounds
• Guidelines for appropriate/desired use
• Antibiotic order sheets
• Prior authorization
• Automatic stop orders
• Selective reporting of susceptibilities
• Computer-assisted programs
Front-end Approach
Physician writes order for “restricted drug”
Order arrives in pharmacy; pharmacist informs physician that drug is
“restricted”/“not part of the pathway”/“nonformulary”
Prescribing physician and the “GATE KEEPER” converse
Approval or alternative antibiotic selected
Back-end Approach
Physician writes order
Antibiotic is dispensed
1) Antibiotic changed or
continued based on
practice guidelines
At a later date, antibiotics are
reviewed
2) Prescribing physician
contacted and
recommendation made
(Targeted list of antibiotics,
culture/sensitivity mismatches,
ICU patients)
Criteria for Selecting Cases for ASP Review
– High-cost agents (eg, linezolid, daptomycin, echinocandins)
– Broad-spectrum agents (eg, carbapenems,
piperacillin/tazobactam)
– High risk of adverse effects (eg, aminoglycosides)
– Intravenous to oral
– Syndromic approach (eg, asymptomatic bacteriuria)
– High-use agents (facility dependent)
– Double coverage of organisms (eg, anaerobes)
– 3 or more anti-infectives for >3 days
– Susceptibility mismatch
Measures
• Process
– Measure surrogate impacts of program
– Accountability
– Resource utilization
– Cost effectiveness
• Outcome
– Most difficult to measure
– Literature suggests improvement in patient and institutional
level antimicrobial susceptibility
– Patient-specific outcomes more difficult to show
Dellit TH, et al. Clin Infect Dis. 2007;44(2):159-177.
Potential Measurements
• Antimicrobial use
– Defined daily dose
– Days of therapy
• Antimicrobial costs
• Timely antibiotic administration and duration
• Cultures obtained before antibiotic(s) administered
• Adverse drug events
• Antimicrobial resistance patterns
• C difficile rates
• Physician’s acceptance of ASP recommendations
What Can Physicians Do?
Can You Improve Through General Guidelines?
• Avoid unnecessary use, especially viral URIs (75%)
• Short course – always wins or ties CAP 3d, HAP 8d
• Automatic stop orders work
• Pathogen-directed therapy
– Microbiology based diagnosis when possible
• Seriously ill – start broad → then pathogen specific
• Play the numbers
– Pathogen always >106/mL
• Dose issue – vancomycin
URI=upper respiratory infection, CAP=community-acquired pneumonia, HAP=hospital-acquired pneumonia.
Reducing Treatment of Asymptomatic Bacteriuria
• Educate about appropriate indication for sending urine cultures
– Signs and symptoms of UTI
– Pregnant women at 12-16 weeks gestation

Treatment prevents pre-term labor and LBW
– Prior to TURP and other urologic procedures where mucosal bleeding
is expected
• Educate about NOT treating positive cultures in the absence of
symptoms in other patients
– Particularly in the following populations

Diabetic women, Older persons in the community or in long term care,
Spinal cord injury patients, Patients with indwelling catheter
Nicolle LE, et al. Clin Infect Dis. 2005;40(5):643-654.
US Preventive Services Task Force. http://www.ahrq.gov/clinic/uspstf/uspsbact.htm. Accessed September 29, 2010.
Lin K, Fajardo K. Ann Intern Med. 2008;149(1):W20-W24.
Implementation of SSI Reduction Efforts
• Should be based in a perioperative care committee
representing leadership from preoperative testing, anesthesia,
operating room (OR) nursing, pharmacy, and infection control
• A physician champion greatly facilitates this activity
• The committee reports to physician leadership through OR
committee or other appropriate group
• A uniformly applied set of standing orders reflecting national
best practices, with limited physician-specific choices, is the
output
Recommended Antibiotic Prophylaxis
Surgical Service
Burns
Cardiac
Thoracic
Colorectal
General surgery/endocrine
Routine Antibiotic
Penicillin or Cephalosporin Allergy
Cefazolin OR cefuroxime
Cefazolin OR cefuroxime
Cefazolin OR cefuroxime or
amplicillin/sulbactam
Cefoxitin OR Cefotetan or
Amplicillin/Sulbactam or Ertapenem OR
Cefazolin plus metronidazole
Clindamycin
Clindamycin OR Vancomycin
cefazolin OR cefuroxime
Cefazolin OR cefuroxime OR
Hepatobiliary (complicated) Cefoxitin OR cefotetan OR ceftriaxone OR
Ampicillin/ sulbactam
Plastics, reconstructive,
Cefazolin OR cefuroxime or
amplicillin/sulbactam
and hand surgery
Vascular
Orthopedics with TJR
Clindamycin OR Vancomycin
Clindamycin OR vancomycin plus
aminoglycoside OR aztreonam or
fluoroquinoline
Clindamycin OR vancomycin plus
aminoglycoside OR aztreonam or
fluoroquinoline
Clindamycin OR vancomycin plus
aminoglycoside OR aztreonam or
fluoroquinoline
Clindamycin OR Vancomycin
Cefazolin OR cefuroxime (add vancomycin
if synthetic graft is being placed)
Clindamycin OR Vancomycin
Cefazolin OR cefuroxime
Clindamycin OR Vancomycin
2011 ASHP Draft prophylaxis guidelines.
Antimicrobial prophylaxis for surgery. Treat Guidel Med Lett. 2009;7(82):47-52.
Addendum: Why not ertapenem for surgical prophylaxis? Treat Guidel Med Lett. 2009; (1320).
American Society of Health-System Pharmacists Web site. http://www.ashp.org/prophylaxis. Accessed October 11, 2010.
IMPLEMENTING ASP IN A
COMMUNITY HOSPITAL
Hospital 1
• Hospital make-up
– 150-bed hospital in a rural setting

Single ICU (4 beds), mostly chronically ventilated patients

Private practice physicians admit patients; no hospitalist team
– ID physician: 2 private practice groups from the community
provide consultation and have admitting privileges
– Pharmacy: 4 full-time pharmacists; pharmacy services from
7:00 AM to 10:00 PM daily
• Formulary structure
– P&T committee chaired by chief medical officer
• Microbiology laboratory: contract service
ICU=intensive care unit; ID=infectious disease; P&T=pharmacy and therapeutics.
Stewardship Program: Option 1
• Form antimicrobial stewardship committee
– Invite members from each ID practice to cochair the committee
– Have representation from key admitting groups within the community
serve on the committee
– Committee reports directly to P&T committee
• Initial stewardship activities
– Antimicrobial formulary
– Daily review of targeted anti-infectives by registered pharmacist
– Prepare antibiogram if not already available
• Resources needed
– 25% to 50% of a full-time equivalent registered pharmacist
– Hourly reimbursement for ID specialist’s time
Stewardship Program: Option 2
• No support from leadership for formal stewardship committee
• Identify key pharmacy champion willing to work on this as a
project
• Take all stewardship initiatives through P&T committee
• Meet with key ID physicians to seek approval of and advice on
initial pharmacy-based stewardship tasks
– Start by reviewing antibiotic formulary
– Intravenous to oral switch programs
– Vancomycin >72 hours without positive culture
Keys to Success for Hospital 1
• Commitment from the private practice ID physicians
– This should be done with support from the hospital for at
least part of their services
• If no reimbursement approved, consider recruiting help
– A good stewardship program can likely decrease the
number of nonbillable “curb-side” calls the groups likely
receive, and most programs still generate a lot of consults
Hospital 2
• Hospital make-up
– 80-bed hospital in a suburb of a midsize city
– No ICU
– Hospitalist service primarily admit patients from 3 large practices in the
area
– ID physician: ID physician visits once per week from local teaching
hospital; otherwise available by phone
– Pharmacy: 2 full-time pharmacists; pharmacy services from
7:00 AM to 7:00 PM daily
• Formulary structure
– Part of a large health system (>20 hospitals) with central
P&T committee
• Microbiology laboratory: contract service
Stewardship Program: Option 1
• No key physician or pharmacist champion with time and
interest to assist with program
• Combine with other institutions within the health system
– Develop system-wide initiatives that could be approved at
system P&T or stewardship committee
– Antibiogram for each institution if not already available
• Initial stewardship activities
– Begin with guidelines for use of formulary agents
– Consider restriction status, given the environment at each
individual hospital
Stewardship Program: Option 2
• Centralized option not feasible
• Find a motivated hospitalist to lead the charge at your institution
– Some hospitalists with ID training in practice
– Perhaps ID physician from training institution is willing to mentor/provide oversight
• Initial stewardship activities
– Guidelines for specific drugs or pathways to standardize treatment of common infectious
diseases
– Antibiogram if not already available
• Resources needed
– Dedicated time for hospitalist to assist
– Will need incremental registered pharmacist, with some training,
to devote time toward this effort
– Evaluate electronic software programs to increase efficiency (may be possible with large
system)
Keys to Success for Hospital 2
• Finding appropriate provider leadership
– Support from local hospital leadership important
– Key decision is whether local provider without ID training
would be respected for ID input vs opinion of larger health
system mandate, which may not be accepted
– Some training programs are proposing abbreviated training
in ID/stewardship; perhaps hospital would be willing to
support some of this training
Hospital 3
• Hospital make-up
–
–
–
–
220-bed community hospital affiliated to large teaching hospital
2 ICUs; total of 20 beds
Trainees staff most services, with hospitalist attending
ID physician: 2 dedicated ID physicians who take small number of
trainees
– Pharmacy: 10 full-time pharmacists, providing 24/7 service; 1 full-time
equivalent pharmacist dedicated to clinical pharmacy activities
• Formulary structure
– P&T committee and antibiotic subcommittee in partnership with
academic medical center
• Microbiology laboratory: on-site at academic medical center
• Hospital leadership requesting stewardship program
Stewardship Program: Option 1
• Wrap efforts into the antibiotic subcommittee initiatives of the health system
• Physician and pharmacist from Hospital 3 join antibiotic subcommittee
• Initial stewardship activities
– Start adapting policies of academic medical center
for approval
– Select strategy of restriction or prospective audit
• Resources needed
– Dedicated pharmacist time (add on to responsibilities of clinical pharmacy
resource vs incremental position)
– ID training for pharmacist
– Support for the ID physicians
– Tools to track outcomes
Stewardship Program: Option 2
• Not able to integrate with academic center program or program does
not exist
• Start separate committee
– Partner with ID physician
– Seek hospital-wide membership; unique to Hospital 3
• Initial stewardship activities
– Create unique antibiogram, if not already in existence
– Outline criteria for use of major drug classes or common disease states
• Resources
– Very similar to Option 1
Keys to Success for Hospital 3
• Getting training for the pharmacist
– ID residency would be ideal, but not realistic given current
supply of programs
– Seek out certificate programs conducted throughout the
country, in some cases with remote options
– Also, consider preceptorships with area institutions that can
help to get less formalized experience, but lots of
real-world knowledge
Centers for Disease Control and Prevention
(CDC) Activities: Improving Use
• Develop a comprehensive Web-based resource to assist clinicians
interested in implementing stewardship programs and interventions
– Background information on antibiotic use
and resistance
– Resources for designing and implementing interventions
• Focus on developing an implementation framework that will make
stewardship activities practical and feasible in any acute care setting
• Collaborating with the Institute for Healthcare Improvement (IHI) and
SHEA to develop a Driver Diagram with practical antibiotic
stewardship implementation strategies with the intent of promoting
aspects of care in places where improvement is needed.
“Get Smart for Healthcare” Campaign by CDC
The Society for Healthcare Epidemiology of America
Resource Toolkit
• To further assist with the implementation of ASPs, an
online tool kit has been developed with this program which
includes:
– Useful resources specifically designed for clinicians at
nonteaching, community hospitals interested in
implementing an ASP
– Practical tools, web links as well as general support
materials
• www.rockpointe.com/ASPtoolkit
What We Hope You’ve Taken From This Program
The Future is Now for ASP
• ASP = Improved Patient Safety and Outcomes
• ASP = Our stand against resistant organisms
• ASP = An improved $ bottom line
To Achieve Success
•
•
•
•
•
Get provider and C-suite buy in
Improve antibiotic use NOW
Scale it up
Measure outcomes
Build on your data
Recommended Resources
• Decreased inappropriate use
– Fishman N. Am J Med. 2006;119(6 suppl 1):S53-S61.
– Solomon DH, et al. Arch Intern Med. 2001;161(15):1897-1902.
– Apisarnthanarak A, et al. Clin Infect Dis. 2006;42(6):768-775.
– Reviewed in Gandhi TN, et al. Crit Care Med. 2010;38(8 suppl):
S315-S323.
• Decreased antimicrobial consumption
– Fraser GL, et al. Arch Intern Med. 1997;157(15):1689-1694.
– Bantar C, et al. Clin Infect Dis. 2003;37(2):180-186.
– Carling P, et al. Infect Control Hosp Epidemiol. 2003;24(9):699-706.
– Cheng VC, et al. Eur J Clin Microbiol Infect Dis. 2009;28(12):1447-1456.
– LaRocco A Jr. Clin Infect Dis. 2003;37(5):742-743.
– White AC Jr, et al. Clin Infect Dis. 1997;25(2):230-239.
– Gross R, et al. Clin Infect Dis. 2001;33(3):289-295.
Recommended Resources
• Adherence with guidelines
–
–
–
–
Reviewed in Gandhi TN, et al. Crit Care Med. 2010;38(8 suppl):S315-S323.
Cheng VC, et al. Eur J Clin Microbiol Infect Dis. 2009;28(12):1447-1456.
Arnold FW, et al. Infect Control Hosp Epidemiol. 2006;27(4):378-382.
Beardsley JR, et al. Chest. 2006;130(3):787-793.
• Better patient outcomes from infection
– Fishman N. Am J Med. 2006;119(6 suppl 1):S53-S61.
– White AC, et al Clin Infect Dis. 1997 25:230-239.
• Reduced length of hospital stay
–
–
–
–
–
White AC Jr, et al. Clin Infect Dis. 1997;25(2):230-239.
Fraser GL, et al. Arch Intern Med. 1997;157(15):1689-1694.
Coleman RW, et al. Am J Med. 1991;90(4):439-444.
Gentry CA, et al. Am J Health Syst Pharm. 2000;57(3):268-274.
Fishman N. Am J Med. 2006;119(6 suppl 1):S53-S61.
• Improved ventilator-acquired pneumonia (VAP) outcomes
– Singh N, et al. Am J Respir Crit Care Med. 2000;162(2, pt 1):505-511.
– Reviewed in Gandhi TN, et al. Crit Care Med. 2010;38(8 suppl):S315-S323.
ANTIMICROBIAL STEWARDSHIP IN
THE COMMUNITY HOSPITAL
Practical Tools and Techniques for Implementation
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