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Policies,Clinical,UW Health Clinical,Medications and Pharmacy

Antimicrobial Stewardship Program (6.1.16)

Antimicrobial Stewardship Program (6.1.16) - Policies, Clinical, UW Health Clinical, Medications and Pharmacy

6.1.16


UW HEALTH CLINICAL POLICY 1
Policy Title: Antimicrobial Stewardship Program
Policy Number: 6.1.16
Category: UW Health
Type: Ambulatory and Inpatient
Effective Date: December 28, 2017

I. PURPOSE

To provide a collaborative, interdisciplinary system for the optimization of antimicrobial use within the
University of Wisconsin Health (UW Health) to improve drug selection, slow the emergence of antimicrobial
resistance, reduce antimicrobial expenditures, and improve patient outcomes.

II. DEFINITIONS

A. Antimicrobial Use Subcommittee (AMUS): a standing subcommittee of the Pharmacy and Therapeutics
Committee that is composed of members from the Infectious Disease Section, Pediatric Infectious Diseases,
Clinical Laboratory Services, and the Department of Pharmacy (see Section IV.F.)
B. Antimicrobial Stewardship Program (ASP): collaborative, interdisciplinary system that promotes the
appropriate use of antimicrobials through the procedures outlined in this document
C. Pharmacy and Therapeutics (P&T) Committee: multidisciplinary group appointed by the Medical Board
provide oversight of all guidelines, policies, procedures, and delegation protocols involving the medication
use process

III. POLICY ELEMENTS

The ASP will work collaboratively to fulfill its purpose through clinical interventions, medication use tool
development, reporting systems, education, and other clinical decision support tools and practices. The
scope of ASP includes all inpatient service areas, but may additionally address antimicrobial issues for the
UW Health Outpatient Clinics, the UW Medical Foundation, and Unity Health Insurance. Additional
collaborative projects may be undertaken with area hospitals. The activities of the ASP will be coordinated
by the AMUS. Additional direction will be obtained from the team’s interactions with the P&T Committee,
Infection Control, Quality Assurance Committees, and Service Oversight Committees.

IV. PROCEDURE

A. The ASP shall be comprised of physicians from the Department of Infectious Disease Section, Pediatric
Infectious Diseases, Antimicrobial Clinical Pharmacists, UW Health Infection Control, UW Health
Microbiology laboratory, and the PGY2 Infectious Disease Pharmacy Resident at UW Health.
B. The ASP shall be responsible for clinical activities relating to infectious disease management and the
prescribing and monitoring of antimicrobial drugs. Antimicrobial products or prescribing patterns may be
prioritized for intervention if they fall into one or more of the following categories: (1) high degree of risk to
patients; (2) excessive use of product; (3) frequent inappropriate use of product; (4) high cost of product.
Clinical activities of the ASP include but are not limited to:
i. Adult and Pediatric Infectious Disease Physicians are available to confer on the weekday review of
antimicrobial orders and to provide supplementary contact to medical staff regarding suggested
changes in antimicrobial therapy. In addition, the Infectious Disease Physician may be contacted
about individual interventions in the following situations:
a. When it is unclear whether an intervention is appropriate for a patient due to comorbidities
b. When an intervention appears to be appropriate but the medical team is unwilling to agree
to the intervention and is unable to provide sufficient reason for the disagreement
c. When a prescriber persists in a prescribing pattern despite repeated interventions by the
pharmacist
d. Other situations at the discretion of the ASP
ii. The Antimicrobial Clinical Pharmacists are responsible for the weekday review of inpatient
antimicrobial orders, initial contact with decentral pharmacists and medical staff to suggest changes
in antimicrobial therapy, and follow-up on interventions.
iii. The ASP shall collect data on the extent of its activities and the status of antimicrobial use in the
hospital. The reports may be distributed as deemed appropriate by the ASP.
C. The ASP, in collaboration with the Drug Policy Program and/or the Center for Clinical Knowledge
management, and the AMUS, is responsible for the development and maintenance of medication use tools



UW HEALTH CLINICAL POLICY 2
Policy Title: Antimicrobial Stewardship Program
Policy Number: 6.1.16

for the appropriate and safe use of antimicrobial drugs. Once approved, these medical use tools shall be
updated by the ASP at regular intervals. Medication use tools include but are not limited to:
i. Formulary Restrictions: New and revised restrictions to UW Health formulary agents must be
forwarded to the P&T Committee and Medical board for full review and approval. Following P&T
Committee and Medical Board approval and according to UW Health Clinical Policy #6.1.17,
Infectious Diseases Section Approval of Restricted Antimicrobial Agents, restrictions may be
implemented and included in the electronic medical record system. Potential restrictions include:
a. Limited location
b. Limited service
c. Limited prescriber
d. Limitations to clinical situation and patient-specific factors
e. Approval through adult and pediatric Infectious Diseases restricted drug pagers
ii. Protocols: New and revised protocols must be forwarded to the P&T Committee and Medical Board
for full review and approval. Following P&T Committee and Medical Board approval, changes may
be implemented. The protocol development process includes:
a. Identifying aspects of antimicrobial drug use that may benefit from standardization and
application of a protocol
b. Determining the most appropriate use of antimicrobial drugs in the specific setting based
on an evidence-based literature review and development of expert consensus among
practitioners
c. Establishing delegation protocols and practice protocols for nurses, licensed practical
nurses, medical assistants, and pharmacists to follow in order to optimize antimicrobial
use therapy and monitoring
iii. Clinical Practice Guidelines: New clinical practice guidelines and revised guidelines with
substantive and/or controversial changes must be forwarded to the P&T Committee and Medical
Board and other committees as appropriate for full review and approval. Following P&T Committee
and Medical Board approval, changes may be implemented.
a. Maintenance of and/or reviews to the UW Health Antimicrobial Use Guidelines and other
clinical practice guidelines which contain or reference antimicrobial agents or the
treatment of infectious diseases will be reviewed by AMUS and approved through the P&T
Subcommittee minutes approval process, unless full P&T review is required.
iv. Policies: Development of new policies or substantial revisions to existing policies for the
improvement of antimicrobial drug utilization at UW Health must be forwarded to P&T Committee
for full review and approval. All other revisions will be approved through the P&T Subcommittee
minutes approval process.
v. Order Sets: Development of order sets may be completed to facilitate appropriate use of
antimicrobials and to standardize care when appropriate.
a. For antimicrobials with special issues regarding dosing, administration, premedication, or
other aspects of use, the ASP may develop computerized order sets specific to those
drugs.
b. Drug-specific questions relating to indication, site, cultures ordered, type of therapy, and
coverage will be included for each antimicrobial order included in the order set.
c. The ASP may develop algorithms for ordering antimicrobials via Computerized
Prescription Order Entry.
vi. Medication Use Evaluations: ASP may conduct assessments of medication use as needed to
characterize antimicrobial use, determine clinical outcomes, and identify opportunities for cost
savings.
D. The ASP is committed to providing education to all staff regarding the safe, appropriate, and fiscally
responsible use of antimicrobial drugs.
i. The ASP may provide opportunities for medical, pharmacy, and nursing staff development through
one-on-one interactions, in-services, newsletter articles, dissemination of information, and other
means as deemed appropriate.
ii. The ASP may educate pharmacy students, residents, and fellows in the appropriate use of
antimicrobials via Drug Use Evaluation studies, the writing of new drug monographs, or other
means as deemed appropriate.
E. The ASP may be an active participant in postmarket approval research and clinical use studies involving
antimicrobial products. This includes:
i. Seeking opportunities to study the effects of antimicrobial interventions on resistance patterns,
costs, and other parameters



UW HEALTH CLINICAL POLICY 3
Policy Title: Antimicrobial Stewardship Program
Policy Number: 6.1.16

ii. Pursuing funding opportunities for such studies from appropriate sponsors of clinical and
epidemiological research
iii. Supporting such studies by informing practitioners, implementing interventions, collecting data, and
performing other tasks as needed
iv. Publishing and presenting the results of its activities in appropriate venues (including journals,
newsletters, scientific meetings, and other settings) as the impact of those activities becomes
evident
F. The activities of the ASP are determined by the AMUS. It will meet at regular intervals to collaboratively
determine the goals and objectives of the ASP and to review the progress of the ASP.
i. Leadership of the AMUS includes Chair and Co-Chair who will jointly identify areas for targeting
studies of antimicrobial use patterns, suggest problems that may exist, and propose interventions
that may be beneficial. They will support the efforts of the ASP by providing leadership to the
respective medical and pharmacy staff, P&T Committee, Infection Control Committee, and the
Medical Board on antimicrobial use issues that are being addressed by the team; peer intervention
and education; and by providing resources to support the activities of the team.
a. Chair: filled by Infectious Disease Physician member and participating member of the full
P&T Committee
b. Co-Chair: filled by Infectious Disease Clinical Pharmacist
ii. Membership of the AMUS includes representation from the disciplines of Adult Infectious Disease,
Pediatric Infectious Diseases, HIV/AIDS, Clinical Laboratory / Microbiology, Infection Control,
Pharmacy, and the Drug Policy Program.
a. Infectious Diseases Physician: identifies antimicrobial use issues, carries out interventions
determined by AMUS, and reports back to AMUS on the progress attained in those
interventions. The Infectious Diseases Physician will provide leadership to the medical
staff through peer interventions and education. The Infectious Diseases Physician will
provide support to the pharmacy staff in the implementation of medication use tools. As
part of the ASP, the Infectious Disease Physician may implement interventions that will
provide cost savings, improve antimicrobial use, enhance understanding of antimicrobial
prescribing practices, and improve patient outcomes.
b. Antimicrobial Pharmacist: identifies antimicrobial use issues, carries out interventions
determined by the AMUS, and reports back to the AMUS on its progress. The
Antimicrobial Pharmacist will provide leadership to the pharmacy staff on antimicrobial use
issues through peer interventions and education. As part of the ASP, the Antimicrobial
Pharmacist will implement interventions that will provide cost savings, improve
antimicrobial use and enhance understanding of antimicrobial prescribing practices, and
improve patient outcomes.
c. Decentral Pharmacy Manager: delineates the Department of Pharmacy goals and
concerns regarding antimicrobial use and proposes targets for interventions across the
health system. The Decentral Pharmacy Manager will support the efforts of the ASP by
providing leadership to the Department of Pharmacy, P&T Committee, and the Medical
Board on antimicrobial use issues that are being addressed by the tam and by providing
resources to support the activities of the team.
d. Drug Policy Program Manager: identifies drug policy issues that relate to antimicrobial use
and suggests methods that may be useful for addressing antimicrobial use problems. The
Manager will support the efforts of the ASP by providing leadership to the Department of
Pharmacy, the P&T Committee, and the Medical Board on antimicrobial use issues that
are being addressed by the team and by providing resources to support the activities of
the team.
e. Drug Policy Program Clinical Pharmacist: identifies antimicrobial use problems and
provides policy support the ASP and AMUS.
iii. The AMUS has the authority to approve or reject revisions to medication use tools originally
approved by the P&T Committee. Eligible medication use tools include policies, guidelines, and
other tools as designated by the full committee that are routinely administered or applied in the
prevention and treatment of infectious disease. Action by subcommittees will be reported to the full
P&T Committee based on full reports during monthly P&T meetings.
a. All protocols and new items, including formulary assessments and medication use tools
(guidelines, policies, or other initiatives as specified by the committee and subcommittee),
will continue to require full review by the P&T Committee, with recommended action
provided by the subcommittees. Final authority for approving decisions remains with the



UW HEALTH CLINICAL POLICY 4
Policy Title: Antimicrobial Stewardship Program
Policy Number: 6.1.16

full P&T Committee.
b. The AMUS will review all requests for additions, deletions, and restrictions of
antimicrobials to the UW Health formulary. The AMUS will also review therapeutic
interchange additions/revisions, and medication route interchange additions/revisions.
iv. The AMUS shall maintain records and reports that document the effects of the interventions carried
out by the ASP. Through the use of technology, such reports may include:
a. Antimicrobial drug usage data and trends
b. Numbers of interventions carried out
c. Antimicrobial susceptibility testing results
d. Infection control, in conjunction with the microbiology lab
e. Qualitative data on antimicrobial drug prescribing patterns
v. The AMUS shall develop and maintain collaborative relationships with UW Health resource
personnel to assist in the development of multidisciplinary intervention strategies and the
monitoring of the effects of interventions
G. The ASP is responsible for the communication of all the goals of the AMUS to the medical staff and
pharmacy staffs for disseminating information about ongoing interventions.
i. Reporting to medical and pharmacy staff meetings will be needed when new interventions are
initiated.
a. The Antimicrobial Pharmacist will communicate individual interventions to the medical staff
while making rounds, with the electronic medical record, or by paging a member of the
patient’s medical team.
b. The Antimicrobial Pharmacist will communicate information about interventions to
pharmacists on the hospital units. The Antimicrobial Pharmacist may also contact the
decentral pharmacists via the electronic medical record, telephone, or paging.

V. COORDINATION

Author: Infectious Diseases Clinical Coordinator
Reviewers: Director of Infectious Diseases
Approval committees: Antimicrobial Use Subcommittee, Pharmacy and Therapeutics Committee, UW Health
Clinical Policy Committee, Medical Board
UW Health Clinical Policy Committee Approval: November 20, 2017

UW Health is a cohesive, united and integrated academic medical enterprise comprised of several entities.
This policy applies to facilities and programs operated by the University of Wisconsin Hospitals and Clinics
and the University of Wisconsin Medical Foundation, Inc., and to clinical facilities and programs
administered by the University of Wisconsin School of Medicine and Public Health. Each entity is
responsible for enforcement of this policy in relation to the facilities and programs that it operates.

VI. APPROVAL

Peter Newcomer, MD
Chief Clinical Officer

J. Scott McMurray, MD
Chair, UW Health Clinical Policy Committee

VII. REFERENCES

UW Health Clinical Policy #6.1.17, Infectious Diseases Section Approval of Restricted Antimicrobial Agents

VIII. REVIEW DETAILS

Version: Original
Last Full Review: December 2017
Next Revision Due: December 2020
Formerly Known as: Pharmacy Departmental Policy #13.17





UW HEALTH CLINICAL POLICY 5
Policy Title: Antimicrobial Stewardship Program
Policy Number: 6.1.16