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Hospital Pharmacy 52(10)
Table 1. Antimicrobial Stewardship Alerts Built in CDSS.
Alert category and name
Type of alert
Therapeutic Antibiotic Monitoring (TAM)
TAM Susceptibility known, inpatient (therapy de-escalation and escalation)a
De-escalation Alert
Vancomycin- and methicillin-susceptible Staphylococcus aureus
Daptomycin/linezolid and ampicillin/vancomycin susceptible Enterococcus
Micafungin and non-Candida glabrata
Escalation Alert
Fluconazole and C glabrata
Micafungin and Cryptococcus spp.
TAM susceptibility known, inpatient
Drug interaction
Ciprofloxacin and contraindicated drug interaction
Itraconazole or posaconazole and proton-pump inhibitor
Itraconazole and contraindicated drug interaction
Protease inhibitors and statins
Rifampin and contraindicated drug interaction
Sulfamethoxazole-trimethoprim and contraindicated drug interaction
Voriconazole and contraindicated drug interaction
ADR monitoring/avoidance
Daptomycin and elevated CPK
Daptomycin and no CPK within 7 days of therapy
Prebuilt
Custom-built
Custom-built
Custom-built
Custom-built
Custom-built
Custom-built
Custom-built
Custom-built
Custom-built
Custom-built
Custom-built
Custom-built
Custom-built
Custom-built
Custom-built
Note. CDSS = clinical decision support systems; ADR = adverse drug reaction; CPK = creatine phosphokinase.
a
TAM susceptibility known alerts occur when susceptibility of an organism is available and marks an opportunity to de-escalate or escalate therapy based
on cultures and susceptibility.
systems help ASPs by providing a means to track resistant
pathogens, antimicrobial utilization, data on patient-specific
microbiology cultures and susceptibilities, patient-specific
factors (eg, hepatic and renal function), adverse drug reactions, and drug-drug interactions. CDSS have both prebuilt
and customizable antimicrobial stewardship-related alerts
which can be created for specific patient care units or for an
entire institution.1,4,5
Prior studies assessing the impact of CDSS on ASPs
have demonstrated process and economic measure benefits
of these technologies by reducing the use of broad-spectrum antibiotics, improving antibiotic dosing, and optimizing the selection of antibiotics. In addition, one study noted
an increased number of intervention rates following implementation of CDSS.1,6 Of note, CDSS reduced the workload of ASP team members by 1 hour per day and resulted
in cost savings of upward of $84 000 over a 3-month study
period.7 Notably, only 24% to 36% of alerts have been
deemed actionable in previous studies.6,8 As the expectations and tasks undertaken by ASPs continue to increase,
the time and efforts allotted for specific tasks (eg, reviewing and intervening on alerts) will have to be managed
accordingly. Of note, there is currently a paucity of data
guiding clinicians on the types of stewardship alerts that
are likely to lead to actionable interventions and the time
that is spent reviewing and intervening on specific types of
alerts. Therefore, we sought to characterize and evaluate
actionable ASP alerts built in a CDSS as part of an
established ASP at a large academic medical center. The
primary objective of our study was to evaluate the types
and percentage of actionable alerts. Secondary outcomes
included acceptance rates of stewardship-related recommendations, time to de-escalation of antimicrobials, time
to appropriate therapy if escalation was needed, and the
time involved assessing and intervening on stewardship
interventions.
Methods
This pilot study was conducted at Cleveland Clinic, part of
the Cleveland Clinic Health-System, a 1400-bed tertiary care
academic medical center. Adult patients (≥18 years or older)
were included in the study if generation of one of 15 prebuilt
or custom-built stewardship alerts (Table 1) occurred from
the CDSS (TheraDocTM). This was a quasi-experimental preintervention and postintervention study, with the intervention referring to the implementation of a CDSS. During the
1-month preimplementation period (March 1-31, 2014),
there was not a consistent method for identifying patients
with ASP-related intervention opportunities or for conducting prospective intervention and feedback for named interventions. During the 1-month postimplementation period
(May 19-June 20, 2014), 15 antimicrobial stewardship alerts
were evaluated in real-time by ID clinical pharmacy specialists or postgraduate year 2 pharmacy residents. These evaluations occurred during the work weekdays (Monday through
Table of Contents for the Digital Edition of Hospital Pharmacy - November 2017
AKD—The Time Between AKI and CKD: What Is the Role of the Pharmacist?
Letter to the Editor
Antithrombotic Therapy Post Endovascular Stenting for Superior Vena Cava Syndrome
Pharmaceutical Pipeline Update
Janus Kinase Inhibitors for the Treatment of Rheumatoid Arthritis
Formulary Drug Reviews
Etelcalcetide
Treatment of Hypertriglyceridemia-Induced Acute Pancreatitis With Insulin, Heparin, and Gemfibrozil: A Case Series
Evaluation of Antimicrobial Stewardship–Related Alerts Using a Clinical Decision Support System
Compatibility, Stability, and Efficacy of Vancomycin Combined With Gentamicin or Ethanol in Sodium Citrate as a Catheter Lock Solution
Development of Institutional Guidelines for Management of Gram-Negative Bloodstream Infections: Incorporating Local Evidence
Underutilization of Aldosterone Antagonists in Heart Failure
Stability of Procainamide Injection in Clear Glass Vials and Polyvinyl Chloride Bags
Development of a Local Health-System Pharmacy Resident Society
Challenges and Solutions to New Manager Onboarding
Hospital Pharmacy - November 2017 - 649
Hospital Pharmacy - November 2017 - 650
Hospital Pharmacy - November 2017 - 651
Hospital Pharmacy - November 2017 - 652
Hospital Pharmacy - November 2017 - 653
Hospital Pharmacy - November 2017 - 654
Hospital Pharmacy - November 2017 - 655
Hospital Pharmacy - November 2017 - 656
Hospital Pharmacy - November 2017 - 657
Hospital Pharmacy - November 2017 - 658
Hospital Pharmacy - November 2017 - 659
Hospital Pharmacy - November 2017 - 660
Hospital Pharmacy - November 2017 - AKD—The Time Between AKI and CKD: What Is the Role of the Pharmacist?
Hospital Pharmacy - November 2017 - 662
Hospital Pharmacy - November 2017 - Letter to the Editor
Hospital Pharmacy - November 2017 - Pharmaceutical Pipeline Update
Hospital Pharmacy - November 2017 - Janus Kinase Inhibitors for the Treatment of Rheumatoid Arthritis
Hospital Pharmacy - November 2017 - Formulary Drug Reviews
Hospital Pharmacy - November 2017 - Etelcalcetide
Hospital Pharmacy - November 2017 - 668
Hospital Pharmacy - November 2017 - 669
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Hospital Pharmacy - November 2017 - 672
Hospital Pharmacy - November 2017 - Treatment of Hypertriglyceridemia-Induced Acute Pancreatitis With Insulin, Heparin, and Gemfibrozil: A Case Series
Hospital Pharmacy - November 2017 - 674
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Hospital Pharmacy - November 2017 - 676
Hospital Pharmacy - November 2017 - Evaluation of Antimicrobial Stewardship–Related Alerts Using a Clinical Decision Support System
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Hospital Pharmacy - November 2017 - 680
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Hospital Pharmacy - November 2017 - Compatibility, Stability, and Efficacy of Vancomycin Combined With Gentamicin or Ethanol in Sodium Citrate as a Catheter Lock Solution
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Hospital Pharmacy - November 2017 - Development of Institutional Guidelines for Management of Gram-Negative Bloodstream Infections: Incorporating Local Evidence
Hospital Pharmacy - November 2017 - 690
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Hospital Pharmacy - November 2017 - Underutilization of Aldosterone Antagonists in Heart Failure
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Hospital Pharmacy - November 2017 - Stability of Procainamide Injection in Clear Glass Vials and Polyvinyl Chloride Bags
Hospital Pharmacy - November 2017 - 703
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Hospital Pharmacy - November 2017 - Development of a Local Health-System Pharmacy Resident Society
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Hospital Pharmacy - November 2017 - Challenges and Solutions to New Manager Onboarding
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