1 Ontario Antimicrobial Stewardship Program (ASP) Landscape SurveyValerie Leung Antimicrobial Stewardship Program Lead Bradley Langford Pharmacist Consultant Julie HC Wu Research Coordinator April 18th, 2017 Image credit: Getty Images/Digital Vision/Siri Stafford Getty Images/iStock/eyegelb

2 Outline Antimicrobial Stewardship 101Antimicrobial Stewardship Landscape Survey Methodology Antimicrobial Stewardship Landscape Survey Results Discussion/Consultation

3 Antimicrobial Resistance is a Public Health ThreatThe Review on Antimicrobial Resistance, Chaired by Jim O’Neill. 2016

4 United States Centers for Disease Control and Prevention. 2016

5 What is Antimicrobial Stewardship?“Coordinated interventions designed to improve and measure the appropriate use of [antibiotic] agents by promoting the selection of the optimal [antibiotic] drug regimen including dosing, duration of therapy, and route of administration” Infection Control & Hospital Epidemiology, Pediatric Infectious Diseases Society . Policy statement on antimicrobial stewardship by the Society for Healthcare Epidemiology of America (SHEA), the Infectious Diseases Society of America (IDSA), and the Pediatric Infectious Diseases Society (PIDS). Infect Control Hosp Epidemiol. 2012;33(4): Available from:

6 Antimicrobial Stewardship is Rapidly GrowingMedline Citations by Year. Source: https://www.ncbi.nlm.nih.gov/pubmed/

7 Antimicrobial Stewardship Programs (ASPs) in OntarioSince 2013, antimicrobial stewardship has been an Accreditation Canada Required Organizational Practice (ROP) for facilities providing inpatient acute care, inpatient cancer, inpatient rehabilitation and complex continuing care services.1 1Accreditation Canada. Required organizational practices: handbook Version 2 [Internet]. Ottawa, ON: Accreditation Canada; 2015 [cited 2016 Dec 16]. Available from: https://accreditation.ca/sites/default/files/rop-handbook-2016v2.pdf

8 Accreditation Canada Required Organizational Practice in Acute CareAn antimicrobial stewardship program has been implemented. (major) The program specifies who is accountable for implementing the program. (major) The program is interdisciplinary, involving pharmacists, infectious diseases physicians, infection control specialists, physicians, microbiology staff, nursing staff, hospital administrators, and information system specialists, as available and appropriate. (major) The program includes interventions to optimize antimicrobial use. (major) The program is evaluated on an ongoing basis and results are shared with stakeholders in the organization. (minor)

9 Antimicrobial Stewardship Programs (ASPs) in OntarioIn 2007, ASPs were rare. (Institute for Safe Medication Practices Canada survey)1 In 2011, 32% of hospitals had an ASP in place. (PHO survey) 1Institute for Safe Medication Practices (ISMP) Canada. Ontario Antimicrobial Stewardship Survey Summary [Internet]. Toronto ON: ISMP Canada; 2007 [cited 2016 Dec 16]. Available from: https://www.ismp-canada.org/abx/downloads/Ont_Abx_Stewardship_Survey_Summary.pdf

10 PHO Antimicrobial Stewardship Strategies Intervention Type Formulary-related Structural/Process Clinical Prescribing Guidance Microbiology-related Program Stage Early Intermediate Advanced Ontario Agency for Health Protection and Promotion (Public Health Ontario). Antimicrobial stewardship strategies [Internet]. Toronto, ON: Public Health Ontario; 2016 [cited 2016 Dec 16]. Available from:

11 Ontario ASP Landscape SurveyPHO initiated a voluntary online survey of hospitals in Ontario in September 2016. Purpose To understand how the landscape of antimicrobial stewardship in Ontario healthcare facilities has evolved since 2013 How many now have an ASP in place? What structural elements are in place? What is the scope of program implementation? To identify priority areas for further advancing antimicrobial stewardship across the province

12 Methodology – Survey DevelopmentQuestions developed by ASP team with advice/input from external stakeholders. Part A: questions on structural aspects of ASP and stewardship strategies that have been implemented. Part B: questions about PHO Antimicrobial Stewardship Resources & Tools. Survey piloted with small number of individuals involved in hospital ASPs. Approved by PHO ethics and privacy.

13 Methodology – Survey DisseminationTargeted distribution list was created based on PHO contacts + Antimicrobial Stewardship Hospital Pharmacists of Ontario Network (ASHPON) + hospital list from Ontario Ministry of Health and Long-term Care (MOHLTC). Voluntary online survey (FluidSurveys) open for 5 weeks from September 19th to October 24th 2016. Distributed to hospitals with instructions that it should be completed by the individual that is most responsible for antimicrobial stewardship in their organization. Intent was to obtain 1 response per organization/corporation unless there are multiple sites and the organization wished to submit separate site-specific responses. Targeted invitation + /telephone reminders to encourage response. No monetary incentive for participating.

14 Methodology – AnalysisIncomplete responses included in analysis. Sites that are primarily Mental Health and Ambulatory were excluded. Efforts were made to eliminate/reconcile unintended duplicate responses. Descriptive analysis performed at an aggregate level (overall, regional) and by hospital type (Acute Teaching, Large Community, Small Community, Complex Continuing Care & Rehabilitation). Hospital type is based on Ontario Hospital Association classification.1 If organization/corporation had multiple sites, classification was by largest hospital type. Bed size was self-reported. 1Canadian Institute of Health Information (CIHI). Hospital Report Acute Care CIHI; [cited 2016 Dec 16]. Available from: https://secure.cihi.ca/free_products/OHA_Acute07_EN_final_secure.pdf

15 Methodology – Regional Analysis

16 Methodology – Screenshot of survey

17 Survey Response Rate - OverallSurvey invitation sent (N=131) Mental health, Ambulatory Care excluded 74% Response rate (n=97)

18 Survey Response Rate - RegionalSurvey invitation sent (N=131) Mental health, Ambulatory Care excluded 74% Response rate (n=97)

19 93% (15/16) 77% 61% (27/44) 79% Survey Response Rate - OverallSmall Community hospitals slightly under represented, Acute Teaching hospitals over represented Acute Teaching Large Community Small CCC & Rehab 93% (15/16) 77% (44/57) 61% (27/44) 79% (11/14) Overall response rate by hospital type Denominator = 131

20 Survey Response Rate - OverallNorth and West regions slightly under represented, Central region over represented Central Central-West East North 91% (31/34) 78% (14/18) 61% (22/36) 58% (11/19) West 79% (19/24) Denominator = 131

21 Overall response rate by hospital typeQ: Do you currently have a formal ASP at your organization? Almost all have or are building a formal Antimicrobial Stewardship Program Overall response rate by hospital type Denominator = 97

22 Acute Teaching Large Community Small Community CCC & RehabQ: Do you currently have a formal ASP at your organization? Small Community and CCC & Rehab hospitals are lagging behind but making progress in establishing formal ASPs Acute Teaching 93% (14/15) Large Community 93% (41/44) Small Community 78% (21/27) 15% in progress (4/27) CCC & Rehab 82% (9/11) 9% in progress (1/11) Denominator = 97

23 Q: Do you currently have a formal ASP at your organization?Small Community and CCC & Rehab hospitals are lagging behind but making progress in establishing formal ASPs Central West East North Acute Teaching 100% (5/5) (1/1) 80% (4/5) (2/2) Large Comm. (18/18) (9/9) 71% (5/7) Small Comm. 67% (2/3) 88% (7/8) 1/8 in progress (8/12) 3/12 in progress CCC & Rehab 1/5 in progress - Denominator = 97

24 Structural elements of antimicrobial stewardship programs in Ontario hospitals

25 Q: What year was your ASP formalized?Overall, ASPs are most mature in Acute Teaching and Large Community hospitals 2013 or prior After 2013 Acute Teaching* 100% (13/13) Large Community* 75% (30/40) 25% (10/40) Small Community* 42% (8/19) 58% (11/19) CCC & Rehab 56% (5/9) 44% (4/9) *Excludes those responded “unknown” to year formalized Denominator = 81

26 # of Respondents with/implementing ASP = 18Q: Do you have a ASC? Most hospitals in the North Region with an ASP have an Antimicrobial Stewardship Committee (ASC) with broad representation # of Respondents with/implementing ASP = 18

27 Q: Is appropriate antibiotic use part of your organization’s quality improvement plan, strategic goal or priority? Just over half acknowledge appropriate antibiotic use as an organizational priority

28 Half of ASPs do not have designated funding/resourcesQ: Are there designated funding/resources for your ASP? Half of ASPs do not have designated funding/resources 50% (45/90) YES 50% (45/90) NO Acute Teaching: 86% (12/14) Large Community: 68% (28/41) Small Community: 12% (3/25) CCC & Rehab: 20% (2/10) Small Community hospitals are least likely to have designated resources for ASPs Denominator = 90

29 Q: Are there designated funding/resources for your ASP?Resource allocation for ASPs in Ontario is currently suboptimal particularly in the East, North and West Regions Central Central-West East North 73% (22/30) 64% (9/14) 21% (4/19) 44% (4/9) West 33% (6/18) Overall = 50% (45/90) Denominator = 90

30 Q: what information does your ASP collect?The most common measures of Antimicrobial Utilization (AMU) are Antimicrobial Expenditures ($) and Defined Daily Doses (DDD) Antimicrobial Expenditures ($) Defined Daily Dose (DDD) Length of Therapy (LOT) 56% 51% 39% 20% Days of Therapy (DOT) Most ASPs also track Antimicrobial Resistance (AMR) and rates of C.difficile infection (CDI) Denominator = 90

31 Strategic elements of antimicrobial stewardship programs in Ontario hospitals

32 PHO Antimicrobial Stewardship Strategies Intervention Type Formulary-related Structural/Process Clinical Prescribing Guidance Microbiology-related Program Stage Early Intermediate Advanced Before we move on to the methodology for our survey, it is important to highlight the strategic components of an ASP, which are addressed in the survey. At PHO, last year our ASP team has released 32 antimicrobial stewardship strategies aimed at the acute care setting. Each document covers a different strategy, discussing the benefits and disadvantages as well as including some examples of how the strategy has been used in hospitals across the province. These are compiled in an online tool that is organized (in a number of ways – but most importantly) by intervention type and program stage. Ontario Agency for Health Protection and Promotion (Public Health Ontario). Antimicrobial stewardship strategies [Internet]. Toronto, ON: Public Health Ontario; 2016 [cited 2016 Dec 16]. Available from:

33 ASP Strategies All survey respondents were presented questions about strategies irrespective of whether a formal ASP was in place. Questions about ASP strategies were grouped according to intervention type: Formulary-Related, Structural/Process, Clinical, Prescribing Guidance, Microbiology-related.1 Brief description of each strategy provided. 1Ontario Agency for Health Protection and Promotion (Public Health Ontario). Antimicrobial stewardship strategies [Internet]. Toronto, ON: Public Health Ontario; 2016 [cited 2016 Dec 16]. Available from:

34 PHO Core Strategies 6/32 designated as PHO Core Strategies.1Determined by PHO ASP team using a consensus-based process. Are all early program stage strategies and intended as a suggested starting point for institutions building their ASP. Intended as guidance only to assist institutions in prioritizing stewardship activities. 1Ontario Agency for Health Protection and Promotion (Public Health Ontario). Antimicrobial stewardship strategies [Internet]. Toronto, ON: Public Health Ontario; 2016 [cited 2016 Dec 16]. Available from:

35 What is a hospital formulary and why is it important?List of drugs that are readily available for use in a specific hospital. Is typically managed by the Pharmacy & Therapeutics Committee (P&T). “List” can also include policies about automatic substitutions, prescribing restrictions of some drugs and drug information. Ideally should be reviewed on regular basis. Has an impact on which specific drugs (antimicrobials) are most commonly used in a particular institution.

36 Formulary automatic substitution (“Auto-sub”)/ therapeutic interchange policiesThese programs allow pharmacists to automatically change an order for a specific drug or dosing regimen without needing to consult the prescriber, according to preapproved procedures and conditions. Benefits: Restrict or direct prescribing to improve pathogen susceptibility, minimize adverse effects and control costs. Example of how to implement: Policies and procedures should be developed by individuals with sufficient expertise and approved by the institution’s senior medical administration (e.g., pharmacy and therapeutics committee). This is a PHO CORE strategy Priority Level: A Difficulty Level: 1 Program Stage: Early Antimicrobial Stewardship Outcomes: Prescribing outcomes 

37 Formulary RestrictionRestricted dispensing of targeted antimicrobials on the hospital’s formulary, according to approved criteria. Restricted antimicrobials may be limited to certain indications, prescribers, services, patient populations or a combination of these. Benefits: Antimicrobial restrictions can help control use, decrease costs and limit antimicrobial resistance. Example of how to implement: Restrict dispensing of targeted antimicrobials by one or more of the following: approved criteria, certain indications, specific prescribers, specific services/wards, specific patient populations. This is a PHO CORE strategy Priority Level: A Difficulty Level: 2 Program Stage: Early Antimicrobial Stewardship Outcomes: Drug utilization outcomes Reduction of Clostridium difficile infection Reduction in antimicrobial-resistant organisms

38 Formulary Review & StreamliningInstitutions are encouraged to review and streamline the number and choice of antimicrobials they have available for use. Benefits: Shown to reduce the costs of targeted antimicrobials and decrease the use of antimicrobials that are unavailable or restricted. May help with specific resistance issues in an institution, since resistance patterns can mirror usage patterns. Example of how to implement: Select one or two representative antimicrobials from each class based on therapeutic efficacy, safety, indications, potential for development of resistance, pharmacokinetics and cost, usually by a pharmacy and therapeutics committee or a similar group. This is a PHO CORE strategy Priority Level: A Difficulty Level: 1 Program Stage: Early

39 Empiric Prescribing GuidelinesMultidisciplinary, evidence-based recommendations using local susceptibility data to standardize and improve the selection of initial therapy for common infectious diseases. Benefits: Improves adherence with standards of care (for some infections, guideline-adherent therapy has been shown to improve patient outcomes). Example of how to implement: Start with established national or provincial guidelines, and/or guidelines from other institutions and adapt for the institution. This is a PHO CORE strategy Priority Level: A Difficulty Level: 2 Program Stage: Early Antimicrobial Stewardship Outcomes: Prescribing outcomes 

40 Intravenous to oral conversion (IV to PO)Intravenous to oral conversion (IV to PO) involves a policy or guideline for switching the route of administration after careful patient assessment. Benefits: Reductions in adverse effects related to the intravenous catheter (e.g., infection, thrombus formation), health care worker workload, patient length of stay, and hospital costs. Example of how to implement: Policies and guidelines to switch to an appropriate oral agent automatically when certain criteria are met. These automatic substitution policies usually pertain to highly bioavailable agents. This is a PHO CORE strategy Priority Level: A Difficulty Level: 1 Program Stage: Early Antimicrobial Stewardship Outcomes: Drug utilization outcomes Clinical outcomes

41 Prescriber Education Education (formal or informal) to inform and engage prescribers and other health care professionals in stewardship activities and to improve antimicrobial prescribing. Benefits: Can result in moderate improvement in prescribing behaviour and acceptance of antimicrobial stewardship strategies. Example of how to implement: Education efforts may be formal or informal. Formal education initiatives may include presentations, staff teaching sessions, written guidelines or policies, and alerts and notices. This is a PHO CORE strategy Priority Level: A Difficulty Level: 2 Program Stage: Early Antimicrobial Stewardship Outcomes: Drug utilization outcomes Prescribing outcomes Reduction of Clostridium difficile infection

42 Q: Your organization has implemented the following ASP strategies:Overall, foundational strategies (PHO Core Strategies) are in place in the majority of hospitals. Hospital Type Empiric antibiotic prescribing guidelines (%) Formulary automatic substitution (%) Formulary Restriction (%) Formulary Review/ Streamlining (%) IV to PO conversion (%) Prescriber education (%) Acute Teaching Large Community Small CCC & Rehab Overall 80 67 73 67 73 87 66 84 59 80 82 68 48 67 41 85 63 33 64 36 36 45 45 45 63 71 54 75 71 59 Denominator = 97

43 Q: Your organization has implemented the following ASP strategies:Foundational strategies (PHO Core Strategies) are most consistently implemented in Central and Central-West Regions. Regions Empiric antibiotic prescribing guidelines (%) Formulary automatic substitution (%) Formulary Restriction (%) Formulary Review/ Streamlining (%) IV to PO conversion (%) Prescriber education (%) Overall (n=97) Central (n=31) Central-West (n=14) East (n=19) North (n=22) West (n=11) 63 71 54 75 71 59 80 80 74 74 68 68 87 87 87 84 36 86 57 93 86 57 74 63 53 68 68 47 41 68 36 64 41 32 73 64 45 54 73 64 Denominator = 97

44 Work effort required to report ASP metrics (64%)Q: Please describe any ongoing challenges to advancing ASP at your organization: Nearly two thirds reported effort to report ASP metrics and IT limitations as challenges to moving local ASP forwards Work effort required to report ASP metrics (64%) Limited IT capabilities (64%) Lack of Infectious Disease expertise (37%) Lack of ability to report ASP metrics (33%) Appropriate antimicrobial use not a publicized hospital priority/strategic goal (21%) Denominator = 90

45 Challenges related to lack of ID expertise and ASP Champions more often identified in North Region

46 Summary of Results ASPs are advancing in Ontario hospitals:2007 – ASPs were “rare” (Institute for Safe Medication Practices Canada survey)1 2011 – 32% of hospitals had an ASP in place (PHO survey) 2016 – 88% of hospitals have an ASP in place, 5% are in the process of implementing Foundational strategies are in place for most hospitals but scope of implementation is variable. Many ASPs in Ontario lack designated resources, particularly in small community and CCC & Rehab hospitals. Work effort to report ASP metrics and IT capabilities cited as additional challenges. Future efforts should address ways to improve resource allocation so that programs can continue to grow in scope and impact. 1Institute for Safe Medication Practices (ISMP) Canada. Ontario Antimicrobial Stewardship Survey Summary [Internet]. Toronto ON: ISMP Canada; 2007 [cited 2016 Dec 16]. Available from: https://www.ismp-canada.org/abx/downloads/Ont_Abx_Stewardship_Survey_Summary.pdf

47 Limitations Voluntary survey – good overall response rate however small community hospitals were under represented. Are non-responders different? Most responses were at the organizational-level; type of strategies and degree of implementation may differ between sites but this is not captured. For FTE calculations, bed-size was self-reported. Details about how and to what degree strategies are implemented were not explored in this survey. E.g., Is Formulary Restriction consistently enforced? Prospective audit and feedback can be operationalized in a variety of ways including services targeted and/or intensity.

48 Sources Accreditation Canada. Required organizational practices: handbook Version 2 [Internet]. Ottawa, ON: Accreditation Canada; [cited 2017 Jan 10]. Available from: https://accreditation.ca/sites/default/files/rop-handbook-2016v2.pdf Antimicrobial Stewardship and Resistance Committee. Association of Medical Microbiology and Infectious Disease (AMMI) Canada. Business Case for Inpatient Antimicrobial Stewardship Programs in Acute Care, Cancer Care, Rehabilitation and Complex Continuing Care [Internet]. Ottawa, ON: AMMI Canada; 2016 [cited 2017 Jan 10]. Available from: https://www.ammi.ca/?ID=126 Association of Medical Microbiology and Infectious Disease (AMMI) Canada. Choosing wisely Canada: five things physicians and patients should question [Internet]. Ottawa, ON: AMMI Canada; 2017 [cited Jan 10]. Available from: Barlam TF, Cosgrove SE, Abbo LM, MacDougall C, Schuetz AN, Septimus EJ et al. Implementing an antibiotic stewardship program: guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. Clin Infect Dis 2016;62: e51–77. Available from: Infection Control & Hospital Epidemiology, Pediatric Infectious Diseases Society. Policy statement on antimicrobial stewardship by the Society for Healthcare Epidemiology of America (SHEA), the Infectious Diseases Society of America (IDSA), and the Pediatric Infectious Diseases Society (PIDS). Infect Control Hosp Epidemiol. 2012;33(4): Available from: Institute for Safe Medication Practices (ISMP) Canada. Ontario Antimicrobial Stewardship Survey Summary [Internet]. Toronto ON: ISMP Canada; 2007 [cited 2017 Jan 10]. Available from: https://www.ismp-canada.org/abx/downloads/Ont_Abx_Stewardship_Survey_Summary.pdf Ontario Agency for Health Protection and Promotion (Public Health Ontario). Antimicrobial stewardship strategies [Internet]. Toronto, ON: Public Health Ontario; 2016 [cited 2016 Dec 16]. Available from:

49 Discussion/Consultation ActivityWe want to hear your thoughts about information you heard in today‘s presentation and learn more about your experience with antimicrobial stewardship your local site!

50 Discussion/Consultation QuestionsThinking about the presentation, did any of the results surprise you? What information is new to you? What kinds of questions do you have about Antimicrobial Stewardship Programs in general? What kinds of questions about antimicrobial stewardship come up in your day-to-day work? What kind of information about antimicrobial stewardship do you look for? Where do you look for this information? Have you come across anything particularly useful? What kinds of interactions do you have with those working within your organization’s Antimicrobial Stewardship program?

51 Discussion/Consultation QuestionsThinking about the presentation, did any of the results surprise you? What information is new to you?

52 Discussion/Consultation QuestionsWhat kinds of questions do you have about Antimicrobial Stewardship Programs in general? What kinds of questions about antimicrobial stewardship come up in your day-to-day work?

53 Discussion/Consultation QuestionsWhat kind of information about antimicrobial stewardship do you look for? Where do you look for this information? Have you come across anything particularly useful?

54 Discussion/Consultation QuestionsWhat kinds of interactions do you have with those working within your organization’s Antimicrobial Stewardship program?

55 Additional slides

56 Resource allocation for ASPs in Ontario is currently suboptimalQ: What is the amount of full time equivalent (FTE) dedicated to ASP for each of the following? Resource allocation for ASPs in Ontario is currently suboptimal Hospital Type Average FTE Physician Pharmacist IT Professional Acute Teaching (N=12) 0.57/1000 beds 2.16 /1000 beds 0.12/1000 beds Large Community (N=28) 0.65/1000 beds 2.55/1000 beds 0.05/1000 beds AMMI Canada Recommendation1 (larger institutions) 1.0/1000 beds 3.0/1000 beds 0.5/1000 beds (Data Analyst) Small Community (N=3) None reported 0.006 CCC & Rehab (N=2) 0.15 0.55 (small institutions, CCC & Rehab) Minimum 0.1 Minimum 0.3 - 1Antimicrobial Stewardship and Resistance Committee. Association of Medical Microbiology and Infectious Disease (AMMI) Canada. Business Case for Inpatient Antimicrobial Stewardship Programs in Acute Care, Cancer Care, Rehabilitation and Complex Continuing Care [Internet]. Ottawa, ON: AMMI Canada; 2016 [cited 2017 Jan 10]. Available from: https://www.ammi.ca/?ID=126 Denominator = 45

57 Q: Your organization has implemented the following ASP strategies:There is opportunity to optimize implementation of foundational strategies in Large Community hospitals in East, West and North regions Large Comm. Empiric antibiotic prescribing guidelines (%) Formulary automatic substitution (%) Formulary Restriction (%) Formulary Review/ Streamlining (%) IV to PO conversion (%) Prescriber education (%) Overall (n=44) Central (n=18) 78 94 83 100 89 Central-West (n=9) 56 67 East (n=5) 60 80 40 North 20 West (n=7) 71 57 29 43 66 84 59 80 82 68 Denominator = 44

58 Q: Your organization has implemented the following ASP strategies:Small Community Hospitals in the Central and North regions have most consistently implemented foundational strategies Small Comm. Empiric antibiotic prescribing guidelines (%) Formulary automatic substitution (%) Formulary Restriction (%) Formulary Review/ Streamlining (%) IV to PO conversion (%) Prescriber education (%) Overall (n=27) Central (n=3) 67 100 Central-West (n=2) East (n=8) 75 63 38 88 13 North (n=12) 33 42 17 West (n=2) 50 48 67 41 85 63 33 Denominator = 27

59 Q: Your organization has implemented the following ASP strategies:CCC & Rehab ASPs are in early stages CCC & Rehab Empiric antibiotic prescribing guidelines (%) Formulary automatic substitution (%) Formulary Restriction (%) Formulary Review/ Streamlining (%) IV to PO conversion (%) Prescriber education (%) Overall (n=11) Central (n=5) 80 20 60 40 Central-West (n=2) 100 50 East (n= 8) North (n=3) 67 33 West (n=0) - 64 36 36 45 45 45 Denominator = 11

60 Systematic Allergy VerificationClarification and clear documentation of allergy status to help optimize the selection of antimicrobials. Benefits: Helps to optimize the selection of antimicrobial agents and/or avoid broad-spectrum or more toxic alternatives. Example of how to implement: This may be performed by the antimicrobial stewardship team, pharmacists, or other clinicians as needed. More advanced service includes pharmacist- or physician-managed penicillin skin testing programs to verify IgE-mediated penicillin allergy in patients who have an unclear history of severe reaction. This is a PHO CORE strategy Priority Level: B Difficulty Level: 2 Program Stage: Intermediate

61 Prospective Audit with Intervention and FeedbackInvolves the assessment of antimicrobial therapy by trained individuals (usually physicians and/or pharmacists), who make recommendations to the prescribing service in real time when therapy is considered suboptimal. Benefits: Has been shown to decrease unnecessary or inappropriate use of antimicrobials. Example of how to implement: Program design can vary with respect to who performs the audits/provides feedback. Options for patient selection can be based on certain infectious conditions, patient location or ward or admitting service, specific antimicrobial agents, duration of therapy, patients at high risk of complications (e.g., for Clostridium difficile infection). This is a PHO CORE strategy Priority Level: A Difficulty Level: 3 Program Stage: Advanced Antimicrobial Stewardship Outcomes: Drug utilization outcomes Prescribing outcomes Reduction of Clostridium difficile infection

62 Q: Your organization has implemented the following ASP Strategies:There is a significant opportunity to increase implementation of systematic Antibiotic Allergy Verification across all hospital types. Program Stage Intermediate Advanced Hospital Type Systematic antibiotic allergy verification (%) Prospective Audit and Feedback Acute Teaching Large Community Small CCC & Rehab Overall 7 80 34 82 11 33 55 55 26 65 Denominator = 97