The State of Antimicrobial Stewardship in Michigan: Results of a Statewide Survey on Antimicrobial Stewardship Efforts in Acute Care Hospitals.

Clinical Pharmacy Specialist, Infectious Diseases, St. Joseph Mercy Health System, Ann Arbor, Michigan; Chief Operations Officer, Michigan Pharmacists Association, Lansing Michigan; Pharmacy Specialist, Antimicrobial Stewardship, Henry Ford Hospital, Detroit, Michigan; Clinical Pharmacist Specialist, Infectious Diseases, Detroit Receiving Hospital, Detroit Medical Center, Detroit, Michigan; ¶Clinical Pharmacy Specialist in Infectious Diseases, Department of Pharmacy and Infectious Diseases, Munson Medical Center, Traverse City, Michigan; Antimicrobial Stewardship Pharmacist, The University of Toledo, Main and Health Science Campuses, Toledo, Ohio; Infectious Diseases Pharmacist, Baptist Health Louisville Pharmacy Department, Louisville, Kentucky; Clinical Pharmacist, Infectious Diseases, Sinai-Grace Hospital, Detroit Medical Center, Detroit, Michigan; Clinical Assistant Professor of Medicine, Wayne State University School of Medicine, Detroit, Michigan. Corresponding author: Curtis Collins, PharmD, MS, BCPS (AQ-ID), FASHP, Clinical Pharmacy Specialist, Infectious Diseases, St. Joseph Mercy Health System, 5301 East Huron River Drive, Ann Arbor, MI 48106; phone: 734-712-6023; e-mail: [email protected] To the Editor: Infections due to drug-resistant organisms are associated with considerable morbidity and mortality.1 While resistant gram-positive infections, such as methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococcus (VRE), remain a significant threat, the rise of resistant gramnegative infections due to P. aeruginosa, A. baumannii, and carbapenem-resistant enterobacteriaceae (CRE) have led to scenarios where clinicians are forced into treatment with highly toxic, often older, and pharmacologically suboptimal treatment regimens with drugs such as polymyxins or tigecycline.2 Despite the Infectious Diseases Society of America’s (IDSA) 10x20 initiative that promotes the development of 10 novel antimicrobials by 2020, the antimicrobial pipeline remains relatively dry, with only a few agents currently in phase III trials and none of these with a novel mechanism of action.3 These data highlight the need for antimicrobial stewardship efforts aimed at promoting the optimal use of current agents in an effort to limit further development of drug resistance. In addition, antimicrobial use, both appropriate and inappropriate, is the number one driver of Clostridium difficile infection (CDI), which has been shown to be a significant complication of hospitalization, leading to increased length of stay, hospital costs, morbidities, and ultimately mortality.4 In 2007, the IDSA developed and published guidelines and recommendations for antimicrobial stewardship within institutions.5 In this document, the authors recommended 2 core methods for stewardship: prospective audit and feedback (which involves daily monitoring of target antimicrobials and direct feedback with the prescribing team) and formulary restriction and preauthorization (requiring approval, usually by infectious diseases [ID], or predetermined criteria to be met, prior to dispensing an antimicrobial).5 They also recommended additional supplemental methods including education, guidelines and pathway development, intravenous to oral switching, de-escalation, and dose optimization to complement the 2 core methods. The authors suggested that the core stewardship team should consist of an ID physician and an ID-trained pharmacist, with support and collaboration of a clinical microbiologist, information technology, and hospital administration.5 Although these recommendations are commendable, the applicability to a large majority of institutions remains questionable and poorly described.