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Infectious Diseases Section Approval of Restricted Antimicrobial Agents (6.1.17)

Infectious Diseases Section Approval of Restricted Antimicrobial Agents (6.1.17) - Policies, Clinical, UW Health Clinical, Medications and Pharmacy

6.1.17


UW HEALTH CLINICAL POLICY 1
Policy Title: Infectious Diseases Section Approval of Restricted Antimicrobial Agents
Policy Number: 6.1.17
Category: UW Health
Type: Inpatient
Effective Date: December 28, 2017

I. PURPOSE

To describe a mechanism for obtaining Infectious Diseases (ID) Section Approval of orders for restricted
antimicrobials.

II. DEFINITIONS

Restricted Antimicrobials: Antimicrobial agents designated by the Pharmacy and Therapeutics committee for
restriction due to safety, efficacy, cost, or availability concerns. The list of restricted antimicrobials is found
in Appendix A and Lexicomp.

III. POLICY ELEMENTS

Designated physicians from the ID Section will review for approval all orders for restricted antimicrobials.
The designated physician will be contacted via a centralized paging system.

IV. PROCEDURE

A. Initial approval
i. The Pharmacy and Therapeutics Committee will determine which antimicrobial agents require ID
Section approval prior to dispensing.
ii. The Department of Pharmacy will maintain a list of current restricted antimicrobials as part of the
UW Health formulary (Appendix A)
iii. The ID Section will designate a physician to be responsible for the approval of restricted
antimicrobials between the hours of 0700 and 2200 via pager #3333 (adults) or #0775 (pediatrics).
iv. The ID Section designated physician will be contacted by the ordering provider or their designee for
approval of all restricted antimicrobials.
v. The ordering physician will provide information to the Infectious Diseases Section designated
physician including full patient name and medical record number and/or date of birth, unit, clinical
condition and clinical rationale for the use of the restricted antimicrobial.
vi. The ID Section designated physician will discuss the appropriateness of the request with the
ordering physician or designee and make a decision on whether or not to approve the order.
a. If the order is approved, the ordering physician or designee will enter the order.
b. If the patient’s attending physician and the designated ID Section physician do not agree,
a bridging supply of the drug may be dispensed until a formal ID consultation is obtained.
c. If a formal consultation is not requested, an informal antimicrobial consultation will take
place for which the ID recommendations and rationale will be documented in the patient’s
medical record. These cases may be followed-up by the P&T Committees for quality
improvement purposes.
d. For both formal and informal consultations a second ID staff physician may serve as an
arbitrator for the case
B. If a need for a restricted antimicrobial is identified between 2200 and 0700, or if a delay in ID Section
approval of greater than one hour is anticipated, the pharmacy may dispense a bridging quantity to initiate
therapy until 1200 and no further doses will be dispensed without ID section approval.
C. If a patient is admitted on a restricted antimicrobial, ID Section approval is still required unless previous ID
Section approval for the specific drug has been obtained for the current course of therapy. Under rare
circumstances where patients have chronically been on restricted anti-infectives, 96 hours of medication
may be dispensed to allow time for review by the antimicrobial stewardship team.
i. Ordering
a. Restricted antimicrobials will include ordering instructions to alert and guide physicians on
this policy
b. All restricted antimicrobial orders will default with a 96-hour stop date/time and include an
order question to document the name of the approving ID Section physician.



UW HEALTH CLINICAL POLICY 2
Policy Title: Infectious Diseases Section Approval of Restricted Antimicrobial Agents
Policy Number: 6.1.17

c. Exemptions to this include: Beacon protocols, inpatient order sets, and antimicrobial lock
orders
D. Approval for continuation beyond 96-hours
i. The Antimicrobial Stewardship Program monitors all patients on restricted antimicrobials daily
Monday thru Friday.
ii. If a patient meets clinical criteria for continuation of restricted antimicrobials the Antimicrobial
Stewardship Program will notify the patient’s primary team and remove the 96-hour stop date/time.
iii. If a patient does not appear to meet clinical criteria for continuation of restricted antimicrobials prior
to the 96-hour stop date/time, the Antimicrobial Stewardship Program will notify the patient’s
primary team by pager or in person to alert them of the need to obtain approval of the ID Section
designated physician for continuation of the restricted antimicrobial.
iv. Exemptions to the restricted use of some antimicrobials (i.e. allowed indications) will be included in
the HealthLink medication record and Lexicomp

This policy does not apply to orders written or suggested in formal consultation by ID Division physicians.

V. COORDINATION

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

Appendix A – List of Restricted Antimicrobials

VIII. REVIEW DETAILS

Version: Original
Last Full Review: December 2017
Next Revision Due: December 2020
Formerly Known as: Pharmacy Departmental Policy #13.19