This presentation describes a pharmacist-led antibiotic streamlining service initiative in hospitals in Beirut, and impact on drug costs, length of stay, and rate of hospital admissions

1. Pharmacoeconomic
Evaluation Of An Antibiotic
Streamlining Service
Nidale Bchara, Marielle Fares, Rania Slika
Pharm.D. candidates
School of Pharmacy
Lebanese American University

2. Outline
 Introduction And Background
 Background
 Rationale
 Objective
 Materials And Methods
 Study Results
 Discussion
 Conclusion

3. Introduction
Health care system with limited financial
resources
Increased pressure to decrease
overall health care bill
Drug cost
Hospital length of stay (LOS )
Rate of hospital admissions

4. Introduction
 30 % of an institution drug budget
Antibiotics
 30% of institutionalized patients On
Antibiotics
 Inappropriate antibiotic usage
 Increasing Cost
 Resistance
Arch Intern Med 1997;157:1689-1694

5. ↑ in
resistance
Increased healthcare
resources
Limited alternatives:
- more antibiotic
-↑mortality
Ineffective empiric
therapy
↑ in
Antibiotic use
Introduction
Relationship between antibiotic use, resistance, treatment failure and
healthcare burden

6. Introduction

7. Introduction
Antibiogram
2002-2003
E.coli* Pseudomonas K.pneumoniae **
AUBMC KAMC AUBMC KAMC AUBMC KAMC
Bactrim 45% 50%
(2423)
- - 78% 76%
(978)
Amox/clav 57% - - - 76% -
Ciprofloxacin 62% 80%
(2424)
88% 84%
(1734)
90% 86%
(978)
Ceftazidime 86% 87%
(2423)
88% 77%
(1733)
75% 76%
(976)
Imipenem 100% 98%
(1485)
85% 82%
(1128)
100% 98%
(667)
Cefotaxime 85% 89%
(2425)
- - 83% 76%
(976)
•* E.coli (ESBL) prevalence: 4.3 % **K.pneumoniae (ESBL) prevalence: 11%

8. Crit Care Med 2001;29:121-127
Introduction
 Resistance
 Intrinsic
 Acquired
 Accelerated by inappropriate Abx use
 Resistance is more prevalent in hospitals
most heavily exposed to antibiotics

9. Introduction
 The impact of resistance underestimated :
 Long-term effect
 Difficult to quantify
 « Cost of Resistance » US 1.3 billion $ annually
 Need of expensive broad spectrum agents
 Need to develop newer antimicrobials (cost of R & D)
 Cost for care: increased LOS, therapy failure or
complications
 Need for isolation, infection control, microbiology,
ID experts
 Sophisticated lab test to detect resistant pathogens
Ann Intern Med 2000;133:128-135

10. Introduction
 Corrective strategies
 Guidelines’ implementation
 Computer assisted technologies
 Educational programs
 Formulary restriction
 Antibiotic streamlining
 Role of pharmacist…

11. Emerging Infectious diseases
2004;10:522-525
Introduction
Corrective Strategies
1. Practice guidelines
 Achieve uniformity of drug use
 Improve prescribing practices
 Decrease costs of therapy
 Disadvantages:
 Passive Educational method , ineffective in changing
prescribing practices
 Threat to professional autonomy : “daily practice= cooking
recipe”
 Low credibility from physicians
 Loss of patient individualization
 Impact on specific patient outcomes not evaluated
 Need for Update, rules and regulations

12. Corrective Strategies
 Educational order forms
 Appropriate dosing of antibiotics
 Pharmacokinetic parameters
 Antibiotic costs
 Computer assisted technologies
 Microbiological sensitivity data
 Alert for resistant organisms
 Algorithms for antibiotic choices towards
specific isolates/indications
Ann Intern Med 2000:133;125-138

13. Corrective Strategies
 Restriction programs
 Implemented in most hospitals
 Formulary restriction
 Automatic stop date
 Requiring approval for usage from ID
specialists
 Shown to decrease cost and resistance
…???  role of antibiotic cycling
 Perceived as authoritarian
Ann Intern Med 2000,133;125-138

14. Corrective Strategies
Antibiotic Streamlining
 In the mid 80’s to describe:
“Converting patients from complicated broad spectrum
parenteral regimen to a single agent with a narrower
spectrum or oral agent as soon as possible ”
 Streamlining is “interchanged” with “transitional”,
“sequential”, “step down”, ”switch” therapy even though
they are not exactly the same…
 Appropriate in managing patients with serious
infections after acute phase of illness (around day 3)
CID 1997;24(Suppl 2)S231-7

15. Antibiotic Streamlining
 Discontinuing of antimicrobial
 NO LONGER NEEDED
 Narrowing the spectrum /regimen change
 After culture and sensitivity results
 Shift to less costly and/or less complex regimen
without compromising clinical efficacy
 Switching to oral therapy if possible
 Ability to tolerate oral medications
 Availability of a oral alternative with good bioavailability
 Patient responding to parenteral therapy
 Optimizing antimicrobial pharmacotherapy
 Therapeutic drug monitoring, adjusting dosage
regimen to maximize benefit from PK/PD

16. Streamlining Advantages:
 Optimizing antimicrobial therapy
 Patient comfort without compromising efficacy
 Judicious usage of abx
 Prevention of side effects
 Minimize resistance
 Cost reduction/containment
 LOS
 Broad spectrum
 Not needed abx
 Resistance cost?

17. Antibiotic Streamlining
ParenteraL to Oral Switch
 Drug Oral Bioavailability
TMP/SMX 90-100%
Levo, Ofloxacin 98%
Moxifloxacin 90%
Clindamycin 90%
Metronidazole 90%
Amox/clav 75%
Macrolides ~50%
Fluconazole ~100%
Physicians were always reluctant to such changes
 Belief that oral agents are less effective
CID 1997;24(Suppl 2):S231-7,
David N. Gilbert,The Sanford guide to Antimicrobial Therapy
2002, 32 nd edition,Hyde Park, p.58

18. Parenteral to Oral Switch
Patient benefit
 Increased mobility ,reducing incidence of
Deep Vein thrombosis and Pulmonary
Embolism…..
 Earlier removal of painful catheter
 Earlier return to usual daily activity
 Improved quality of life
 Restoration of autonomy and mobility
 Better participation in his/her own healthcare
 Earlier return to his/her environment
CID1997;24(Suppl 2):S231-7

19. Parenteral to Oral Switch
Cost Containment
 Early switching to oral route
 Reduces drug administration and acquisition
costs
 Parenteral drug costs
 Supply costs of catheters and tubings.
 Nursing and pharmacist time reduction.

20. Cost of Antibiotics
AUBMC contract pricing 2004
Drug IV route
Cost/Unit (l.l.)
Oral route
Cost/ unit (l.l.)
Ciprofloxacin 120,000/ 400 mg 6,600/ 500mg
Levofloxacin 78,000/ 500 mg 9,000/500 mg
Fluconazole 71,000/ 200mg 28,000 /150 mg
Pip/tazo 55,000/4.5g
Amox/clav 10,000/1.2g
Ceftizoxime 17,000/1g

21. Parenteral to Oral Switch
Cost Containment
 Am J Health Syst Pharm 2002,59(22):2209-2215
 Objective: Assess economic and clinical
outcomes of a pharmacist active intervention
program using a 3 level economic
analysis.(drug, supplies, length of stay)
 Methods :2 month period , comparison of an
observational group (n=82) to an active
conversion program of iv to po
levofloxacin(n=49)
 60% patients were candidates in each control
and intervention grp after 3.4 d
 Costs (drug /supplies/administration) were
sig. less among active conversion grp 91$
than observational grp 155 $ (p=0.002)

22. Parenteral to Oral Switch
Cost Containment
 Reduction of Adverse effects related
costs : Catheter’s complications
 Bacteremias
 Phlebitis
 Cost of treating 1 episode of catheter
related sepsis is : 4000-6000 $
(CID1993;16:778-84)

23. Parenteral to Oral Switch
Cost Containment
 Early Switch to PO may lead to earlier
hospital discharge
 May reduce LOS by a mean of 2.4 days
Infect Control Hosp Epidemiol 1992;13;21-32
 ‘’Switch to oral levofloxacin’’ program proved
less LOS costs : 13,931$ (switched pt ) vs
17,198 $ (candidate pt) (p=0.021)
Am J Health Syst Pharm 2002;59(22),2209-2215
 Reduction in LOS may save 884$-1291$
per patient in hospital and drug bed costs
Arch Int Med 1995;155:1273-6
Ann Pharmacother1995;29:561-5

24. Inappropriate Antibiotic Usage
 Common errors seen in practice include:
 Overuse of intravenous drugs
 Prolonged courses of antibiotics
 Use of agent with inappropriate spectrum
 Administration of an antibiotic with no
evidence of infection
JAC 2004, vol 54 no2, 295-298

25. Inappropriate Antibiotic Usage
In Lebanon
 Am J Health Syst Pharm 2003;60:934-9
 Objective: Evaluation of management of CAP for
consistency with IDSA guidelines
 Methods : 6 month period, n=65
 Results: Consistency with guidelines, BUT…
 Discussion :
 Antimicrobial prescribing practice needs
improvement
 Iv Levofloxacin overused, may be replaced by a
macrolide and beta lactam, according to risk
levels

26. Role of ID Pharmacist
Early 1980’sPharmacoeconomic Role of the
Clinical Pharmacist :
 Engage in patient rounds , discuss dosing and
side effects  Optimization and
individualization of pharmaceutical care
 Pharmacokinetic services (therapeutic drug
monitoring)
 Anticoagulation, diabetes, HIV, lipid, asthma,
and immunization clinics

27. Role of ID Pharmacist
 Integration of all data from microbiological lab,
medical / financial records, individual patient
information
 Monitoring daily use of antimicrobials, and
deviation from restriction programs / guidelines
 Assisting in policy development related to Abx
 Conducting educational campaigns to house
staff/other health care professionals

28. Role of ID Pharmacist
 Cannot accomplish his role unless
 Part of a multidisciplinary team with
infectious disease specialists, infectious
control personnel, microbiologists….
 Develop constructive relationship with
the team members leading to trust and
respect
JAC 2004, vol 54 no2, 295-298

29. Role of ID pharmacist
 Needs to be more active inside the team
 Write suggestions on medical records
Arch Inter Med 1997;157:1689-1694
 Randomised controlled trial n=260
 3 month Antibiotic Streamlining service run by a
multidisciplinary team including a clinical
pharmacist
 Patient specific antibiotic related suggestions were
placed in the medical record in the intervention
group
 50% pts could be safely streamlined after 3 days.
 Antibiotic charges were reduced by 400$ /patient

30. Rationale
 Economic crisis in Lebanon
 Inappropriate Antibiotic Usage in various
hospitals
 Emergence of resistance in lebanon
 Previous data from lit. showing benefits
of Streamlining service
 No Pharmacoeconomic study on
multidisciplinary Antibiotic Streamlining
in Lebanon

31. Objective
 To evaluate the economic and outcome
benefit of a potential multidisciplinary
antibiotic streamlining service composed
of clinical pharmacists and ID specialist.

32. Materials and Methods:
1. Setting
The American University of Beirut Medical
Center (AUBMC)
 a 400-bed
 university medical center
 acute and tertiary care
 Patients of all ages in Lebanon and
the region

33. Materials and Methods:
2. Study Design
 Prospective Observational Evaluation
conducted over a two months period
from April, 2004-June, 2004
 Study protocol was reviewed and
approved by the Institutional Review
Board and Ethics Committee at AUBMC

34. Materials and Methods
3. Patients
Patients identified from pharmacy record of
restricted antibiotic orders
 Inclusion criteria:
 > 18 yrs of age
 Receiving restricted antibiotics >72 hrs
 Exclusion criteria :
 < 18yrs of age patients
 Patients with serious infections (meningitis,
endocarditis, undrained abscesses)

35. AUBMC Restricted Antibiotics
P & T 4/2003
Amikacin
Amphotericin B
Aztreonam
Caspofungin
Ceftizoxime
Cefotaxime
Cefepime
Cefodizime
Ceftriaxone
Ceftazidime
Piperacillin/Tazobactam
Imipenem
Vancomycin
Teicoplanin
Ciprofloxacin IV
Fluconazole IV
Levofloxacin IV
Ofloxacin IV

36. Materials and Methods
4. Streamlining
 Prospective evaluation of medical records and
patient data from the first day of restricted
antibiotic administration
 Data collected on special flow charts and
included medical history, patient clinical status,
and medication used
 If Candidates for streamlining after 72 hrs of
the therapy , the recommendation was
communicated verbally to the medical team

37. Criteria for Streamlining
 Clinical stability
Decline in peak temperature
Normalizing white blood cell count
Systolic blood pressure >90 mmHg
Heart rate <100 bpm
 Resolving Signs and Symptoms of
infection
 A clinical response is noted
 Availability of culture growing a pathogen
sensitive to a narrower spectrum agent

38. Criteria to Switch IV to PO
 Hemodynamic stability of the patient
 Resolution of signs of infection
 Integrity of gastrointestinal function
 Ability to tolerate oral medication, oral intake
 Oral bioavailability maintained

39. Materials and Methods:
4. Streamlining
 Types of recommendations
 Regimen changes (simplifying regimen to
a single narrow agent)
 Dosing changes
 Intravenous to oral antibiotic conversions
 Discontinuance of antibiotics
 The final decision of accepting or
rejecting a recommendation is made
solely by the treating physician

40. PROTOCOL Overview
Accepted
Primary endpoint
Cost of antibiotic used
• oral
• parenteral
Secondary endpoint
Outcome assessment
• Mortality
• Cure or improvement
• Length of stay
• Rehospitalisation rate
Primary endpoint
Cost of antibiotic used
• oral
• Parenteral
Secondary endpoint
Outcome assessment
• Mortality
• Cure or improvement
• Length of stay
• Rehospitalisation rate
Data collection +
Measure Recommendations Outcomes
Refused

41. Materials and Methods
5. Pharmacoeconomic analysis
PART I
Comparing accepted vs rejected recommendations
The economic Impact assessed in a 2 level analysis
 Level 1: acquisition price of antibiotic used
 Level 2 : in addition cost related to antimicrobial
use (supplies, pharmacy time and nursing time and
treatment of adverse effects)
 Medication costs were obtained from AUBMC
contract pricing of 2004

42. Materials and Methods:
5. Pharmacoeconomic analysis
PART II
Comparing accepted vs rejected recommendations
The defined daily dose was used to quantitate the intensity of antibiotic use
 Defined daily dose (DDD):
Average adult maintenance dose for the primary indication of the drug
 DDD :Unit of measurement endorsed by the WHO as a mean to
compare drug use among populations
 Number of DDD = (qtty of drug X Strength )
WHO ddd
 Sum DDD= Added ‘’number of ddds’’ for the same drug for all patients
 Cost/DDD

43. Materials and Methods:
5. Pharmacoeconomic analysis
 Cefepime 2g q12 for 10 days
 DDD: 2g
 # DDD= 40 × 1g = 20
2g
 L1’ = 40 × 25,250 L.L.( price of 1g vial)
= 1,010,000 L.L.
 L2’ = L1’ + NT(1000 L.L/infusion)
= 1,030,000 L.L.
 Cost/DDD = 2g × 20 × 25,250 L.L
= 1,010,000 L.L

44. Statistical analysis
 Descriptive statistics were used

45. Results

46. Results
N (%)
207
59
18-94
127(39%)
80 (61%)
81 (39%)
26(13%)
9 d ± 6
Patient characteristics
Total
Age, mean yrs
Range
Gender
Male
Female
Hospital admission within 1 month
Cx with resistant pathogen within 1yr
LOS, mean days ± SD

47. Results
Infection characteristics
 Infection distribution
 Nosocomial 36.8%
 Community 63.2%
Surgical
Prophylaxis, 20
SSTI, 13
Abdominal
Infections, 15
UTI, 42
LRTI, 53
Febrile
Neutropenia, 7

48. Results
Infection characteristics
 Culture site* N (%)
Total 172
Urine 63 (36.7%)
Blood 37 (21.5%)
DTA 27 (15.7%)
Sputum 10 (5.8%)
Others 35 (20.3%)
* Include all cultures (with or without growth)

49. Results
Infection characteristics
 Breakdown of pathogen isolated
 Pathogens
isolated
( N=130* )
*The remaining are fungi
Gram +
Gram -
S. Pneumo (1)
S. Aureus (9)
S. Epi (14)
Others (3)
E.Coli (44)
Pseudomonas (22)
Klebsiella (8)
Others (19)

50. Results
Infection characteristics
 Resistant pathogens 2002-2003
MRSA 4/9 (44.4%) (AUH 26%)
MRSE 8/14 (57%) (AUH 69%)
MDRPA 7/22
ESBL (AUH 4.3%)
(AUH 11%)
E.Coli 22/44 (50%)
Klebsiella 2/8 (25%)

51. Results All Patients (207)
Rec group (80) Nonrec group (127)
Accepted rec
(6)
Nonacc Rec
candidates
(74)

52. Results
Recommendations Distribution
*more than one recommendation was done on some pts
38.6%
80/207 patients
Recommendations
42.5%
88/207
# of recommendations*
7.5%
6/80 patients
Accepted recommendations
8.75%
7/80
# of accepted recommendations

53. Results
Types of recommendations 88 Cost savings/2m
25
Converting broad spectrum to a
narrower spectrum
• Tazocin cefoxitin (Aug)
24
Dosing regimen changes
•Tazocin q6 q8
•Cefepime q8 q12
23
D/C abx
13
Switching IV PO
3
Switching amikacin gentamicin
25,753,050 L.L
9,046,550 L.L
15,714,750 L.L
5,125,250 L.L
434000 L.L

54. Results
Antibiotic use and cost
Comparison of the sum of DDDs among all pts prior to
recommendations
SUM DDDs
nonRec (127)
Rec (80)
All pts (207)
862
1061
1923
Parenteral
25
0
25
Oral
787
922
1709
Restricted
100
139
239
Nonrestricted

55. Results
Comparison of the sum of DDDs among the Recommended
group Sum DDDs
Total Rec (80)
Rej Rec (74)
Candidates
Acc Rec (6)
With Rec
No Rec
With Rec
No Rec
With Rec
No Rec
471
1061
413
976
58
85
Parenteral
163
0
149
0
14
0
Oral
305
922
270
837
35
85
Restricted
329
139
292
136
37
3
Nonrestricted

56. Results
Cost savings among the recommended group/2m
*L1’: cost savings per drug/2m
L2’: cost savings per drug & nursing time/2m
pharmacy salary: 1,200,000 L.L/m
Total Rec (80)
Rej Rec (74)
Candidates
Acc Rec
(6)
55,080,600
52,676,600
2,404,000
L1’*/L.L
56,073,600
53,626,600
2,447,000
L2’*/L.L
73,580,650
70,616,650
2,964,000
Cost/DDD
53,673,600
51,226,600
47,000
L2’-pharmacy
salary (L.L)*/2M

57. Results
Cost savings among recommended group/year
Total Rec
Rej Rec
candidates
Acc Rec
322,041,600
307,359,600
282,000
Cost savings/yr
(L.L)

58. Results
Cost (L.L.)/ddd
sum DDDs
No Rec With Rec
No Rec. With Rec
9,090,000
11,312,000
180
224
Cefepime
0
14,641,000
0
121
Ceftazidime
660,000
16,500,000
4
100
Piperacillin/tazo
3,850,000
7,546,000
50
98
ceftriaxone
0
9,702,000
0
63
Imipenem
0
9,750,000
0
65
Ciprofloxacin
0
888,000
0
24
Amikacin
Comparison of sum Of DDDs & cost in the most
commonly used RESTRICTED abx among the
Rec group

59. Results
Comparison of sum Of DDDs & cost in the most
commonly used NON RESTRICTED abx among
the Rec group
Cost (L.L.)/ddd
sum DDDs
W/O interv. W interv.
W/O interv. W interv.
693,000
18,000
77
2
Gentamicin
640,000
0
32
0
Augmentin IV
79,200
0
63
0
Augmentin PO
5,742,000
0
44
0
Cefoxitin
144,000
0
12
0
Ciprofloxacin
PO

60. Results
Comparison of outcome among the recommended group
Total
(207)
Non-rec
(127)
Rej Rec
(74)
Acc Rec
(6)
Outcome
5
5
0
0
Death
190
113
72
5
Cure
3
3
0
0
Relapse
9
6
2
1
Rehospitilization
9 d
8d
11 d
10 d
Mean LOS

61. Discussion
Summary of the results:
---I) 38.6 % candidates for streamlining (80/207
patients)
 ~7.5% only accepted (6/80)
 Very low rate of acceptance (vs.~80% in other
studies in U.S.A)
Arch Intern Med. 1997; 157: 1689-1694

62. Discussion
Reasons for not accepting our recommendations:
 Third party reimbursement concerns
 Difficulty communicating with medical team
 Resistance to change
 Outcome concerns
 “In the broad spectrum, we trust” theory
 Graduate students, not part of managing team
 Medical team verbally agreed with
recommendation but the orders were not
changed
 For some unknown political/geographical/regional
reasons..

63. Discussion
Approaches to increase acceptance:
 Placement of suggestion in the medical record
 Intervention initiated by opinion leaders in ID
 Patient-specific educational materials
 Direct physician contact, pharmacist being part of the
team
 Third-party reimbursement law modifications??
Arch Intern Med. 1997; 157: 1689-1694

64. DISCUSSION
Summary of the results:
---II) ON 6 patients : Yearly savings by
extrapolation: 14 682 000 L.L
 Pharmacist salary /year: 14 400 000 L.L
NET BENEFIT
282 000 L.L

65. DISCUSSION
No big-time win but NO LOSS ?!!
HOWEVER
“ A better job could be done for 74 other patients”

66. DISCUSSION
 on 80 candidates:
Savings/2 months = 56 073 600 L.L
Pharmacist salary/2months = 2 400 000 L.L
NET BENEFIT / YEAR = 322 041 600 L.L

67. Discussion
Summary of the results:
---III) > 75% of reported recommendations :
 Narrowing spectrum
 Dosing changes
 discontinuing unnecessary antibiotic
 Switching from IV to PO
> 50% of savings come from ”easy recommendations..”:
 Inappropriate dosing, unneeded antibiotic
 Cefepime 2g q8h
 Piperacillin/tazobactam 4.5g q6h

68. DISCUSSION
 ---IV) restricted vs non restricted
 Decrease in restricted abx use in favor of non restricted
 Certain drugs issue: cefepime, imipenem…
 Knowing use of restricted before could have been less
Formulary restriction:
 Identified specific drug-problems:
 Restriction on the restriction
 “Antibiotic cycling”: more appropriate for AUBMC?
 Other strategies?

69. Discussion
---V) Impact on resistance:
- short- term study
- “Alarming numbers” for AUBMC
- “ Bad bugs, No drugs”

70. Discussion
AUBMC
antibiogram
2002-2003
E.coli* Pseudomonas K.pneumoniae **
Ciprofloxacin 62% 88% 90%
Ceftazidime 86 88 75
Imipenem 100 85 100
•* E.coli (ESBL) prevalence: 4.3 %
•**K.pneumoniae (ESBL) prevalence: 11%

71. DISCUSSION
---IV) secondary outcomes
 Length of stay
 Patient outcomes
Could not be assessed properly due to our major
limitation: “Low acceptance rate”

72. Discussion
Limitations :
 Non- controlled
 short-term study
 Low acceptance rate by physicians
 not implemented
 Patients lost to follow-up

73. Recommendations
 Urgent need for well-structured Antibiotic
Management Program (AMP)
 Goal : Optimizing antibiotic use according to the
best available scientific evidence:
 Do not use antibiotics when not needed
 Target the narrowest possible spectrum
 Deliver them in correct concentrations, at the right time,
using the safest route, to the right patient
 Use the most cost- effective alternative

74. Recommendations
 Antibiotic management program (AMP)
 Form a team to:
 Distribute workload
 Integrate diverse interests
 Arbitrate disputes
 clinical pharmacist , microbiologist, ID specialist,
infection control specialist.
 All individuals implicated in AMP should disclose potential
conflicts of interest

75. Recommendations
 Adapting AMP to institution (AUBMC)
 Patient population
 Nature of the services
 Recent trends in antibiotic use/costs, prevalence of
resistance…
 Problem-areas: certain drugs, departments…
 Identify potentially useful interventions

76. ANTIBIOTIC
NEEDED?
Check C/S
results
Deliver
antibiotic
Prescribe
antibiotic
Choose
antibiotic
Correct spectrum
Class?
Cheapest
Alternative?
Yes
Yes
No
No
STOP!
STOP!
No
Yes

77. Choose ABX
RESTRICTED?
No Yes
Prescribe
ABX
Yes Yes
No
No
Follow guidelines? Justified?
Optimal
dose/interval/route?
Deliver ABX
Correct
patient/dose/time?
Check C/S
results
Correct spectrum
class?
Yes
Yes
Yes
STOP!
ABX needed?
No Yes
No
No
No
At 48-72
hrs

78. Recommendations
 “Restriction on the restriction”, antibiotic cycling
 Automatic stop-date, automatic switch
 Rapid C/S results, MIC…
 Empiric therapy consult ?
 Continuing education