a. General Principals
One of the greatest drivers of antimicrobial resistance is antimicrobial overuse. To combat antimicrobial resistance, all EHC hospitals have Antimicrobial Stewardship Programs (ASP). The primary goal of these programs is to optimize clinical outcomes while minimizing unintended consequences of antimicrobial use, including toxicity, the selection of pathogenic organisms (such as C. difficile), and the emergence of antimicrobial resistance. The programs are co-led by physicians and pharmacists (see list at the end of the study guide). Their overall activities are coordinated by CASE, the Committee for Antimicrobial Stewardship at Emory Healthcare.

Multiple activities fall under the scope of the ASPs, including some related to individual patient care (such as audit and feedback to providers on their individual prescribing habits or review of positive blood cultures to ensure patients receive appropriate treatment) and others related to broader use of antimicrobials (such as the development of clinical protocols and the systematic conversion of IV to PO antimicrobials). You may be contacted by a member of the stewardship team regarding antimicrobials for an individual patient to discuss route of administration, optimal treatment and duration, when appropriate. For some antibiotics, such as vancomycin, dosing is adjusted using a pharmacy protocol. Contact your institution's ASP team, for any questions regarding optimizing antimicrobial use at your institution.

Multiple activities fall under the scope of the ASPs, including the development of clinical protocols, collecting data on antimicrobial use, and providing education regarding antimicrobial use. You may be contacted by a member of the stewardship team regarding antimicrobials for an individual patient. The hospitals may have initiatives to switch from IV to oral therapy when appropriate and to help determine the best duration of treatment for your patient. For some antibiotics, such as vancomycin, dosing is adjusted using a pharmacy protocol. Contact your institution's ASP team, for any questions regarding optimizing antimicrobial use at your institution.

b. Antimicrobial Stewardship Resources at Emory
The ASPs at EHC have created a variety of resources to assist providers with optimizing antimicrobial use. These include treatment guidelines for Mpox, community-acquired pneumonia, and urinary tract infections, among others. The stewardship teams also collaborate with the microbiology lab to create an antibiogram for the most commonly isolated bacterial pathogens at each hospital. The antibiogram shows what percent of common bacteria isolated at that facility are susceptible to commonly used antimicrobials and can assist with selecting appropriate empiric antimicrobial therapy prior to complete susceptibility results returning. There are also guidelines for antimicrobial dosing in the setting of renal dysfunction and recommendations on antimicrobial selection in the setting of penicillin allergy. All of these resources can be found in the Emory Healthcare Antimicrobial Stewardship section of the uCentral app from Unbound Medicine, through the virtual desktop, or within the Clinical Resources section of Epic.

c. Restricted Antimicrobials
Each hospital has a list of restricted antimicrobial agents that are orderable only by infectious disease providers or select other services. The list of agents and the procedures for ordering are outlined on the uCentral EHC ASP app. This list is based on antimicrobial cost, spectrum of activity, and toxicities. If an ID consult team is not actively following the patient and a restricted antimicrobial is needed, then the ID attending on call should be contacted to discuss the case and request the agent. The approving ID provider's name should be entered in the order as 'Authorizing Provider'.

d. Required Infectious Disease Consults
There is established literature on improved patient outcomes, including reduced mortality, associated with infectious disease consultations for several bloodstream infections. Given the complexity of management of these patients both in the inpatient setting and after discharge, EHC requires infectious disease consultation for any patients with bloodstream infections with Staphylococcus aureus (both methicillin-susceptible and methicillin-resistant), Staphylococcus lugdunensis, Enterococcus species and yeast/Candida species.