Advanced

Antimicrobial
Stewardship
THOMAS J. DILWORTH, PharmD
Pharmacy Coordinator, Infectious Diseases
Program Director, PGY2 Infectious Diseases Residency
Aurora St. Luke’s Medical Center

RAMY H. ELSHABOURY, PharmD, BCPS AQ-ID

Clinical Pharmacy Manager, Infectious Diseases, Surgery & Transplant
Pharmacy Services
Director, PGY2 Infectious Diseases Pharmacy Residency
Massachusetts General Hospital

PCAC
Pharmacy Competency Assessment Center
EDITORS
JOEL A. HENNENFENT, PharmD, MBA, BCPS, FASHP
Chief Pharmacy Officer & Associate Administrator for Laboratory and Imaging Services
Truman Medical Centers in Kansas City, Missouri

HEATHER A. PACE, PharmD

Assistant Director, Drug Information Center
Clinical Associate Professor
Division of Pharmacy Practice and Administration
University of Missouri ─ Kansas City School of Pharmacy

SECTION EDITOR
KERSTEN WEBER TATARELIS, PharmD, BCPS AQ-ID
Vice President, Pharmacy Operations
Advocate Aurora Health

®
© 2019, American Society of Health-System Pharmacists
2 PCAC - Pharmacy Competency Assessment Center

CE ACCREDITATION
INFORMATION
The American Society of Health-
System Pharmacists is accredited
by the Accreditation Council for
Pharmacy Education as a provider of
continuing pharmacy education.

ACPE #: 0204-0000-19-042-H01-P 
Release Date: July 15, 2019
Expiration Date: July 15, 2022
CE Credits: 1.0 hour
Activity Type: Application-based

Claiming ACPE Continuing Pharmacy Education Credit

This module has been assigned an ACPE universal
activity number (UAN). There is no limit to the
number of times that this module may be completed;
however, continuing pharmacy education may be
Editorial Consultant: Toni Fera, BS Pharm, PharmD
claimed by an individual only once per module.

© 2019, American Society of Health-System Pharmacists, Inc. All

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The information contained in this program is constantly evolving
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© 2019, American Society of Health-System Pharmacists

 ADVANCED ANTIMICROBIAL STEWARDSHIP  3

TABLE OF CONTENTS LEARNING OBJECTIVES

I. Introduction 1. Explain contemporary antimicrobial

consumption metrics.
II. Antimicrobial Dose and Route
Optimization 2. Compare methods to reduce the
III. Antimicrobial Duration and Timeout duration of empiric antimicrobial
therapy.
IV. Antifungal Stewardship
3. Illustrate ways in which pharmacists
V. Rapid Diagnostics can engage in antimicrobial dose
optimization.
VI. Antimicrobial Consumption Tracking
VII. Clostridium Difficile-Associated 4. Apply strategies to reduce the
Diarrhea impact of beta-lactam allergies on
antimicrobial therapy selection and
VIII. β-Lactam Allergy antimicrobial use outcomes.
IX. Conclusion
X. References

© 2019, American Society of Health-System Pharmacists

4 PCAC - Pharmacy Competency Assessment Center
INTRODUCTION
Antimicrobial stewardship (AMS) has been a part of
most pharmacists’ practice for years, but recently it
has become the subject of national standards. The
Infectious Diseases Society of America (IDSA) AMS
guidelines, the Centers for Disease Control and Preven-
tion (CDC) guidelines, The Joint Commission (TJC)
Medication Management standard, and the Centers
for Medicare & Medicaid Services (CMS) Conditions
of Participation, as well as the 2015 National Action
Plan for Combating Antibiotic-Resistant Bacteria, all
support AMS efforts.1-5 Pharmacists are well positioned
to manage advanced pharmacotherapy interventions
aimed to optimize antimicrobial use and antimicro-
bial use outcomes. The basic elements of AMS were
discussed in the module entitled General Antimicrobial
Stewardship. This module builds on those concepts
presented earlier and provides further guidance to
general pharmacy practitioners seeking to engage in
more advanced AMS interventions.
ANTIMICROBIAL DOSE AND
ROUTE OPTIMIZATION
Optimizing antimicrobial dosing and route of admin-
istration represent perhaps two of the basic pillars
of AMS programs. Most often they represent the
initial building blocks for new programs aiming to gain
acceptance and credibility in the early stages of imple-
mentation. Foundational, and often less controversial,
protocols such as standard renal dosing and intravenous
(IV)-to-enteral conversion protocols help to establish
the role and presence of the new AMS program across
the institution. Such protocols rely on widely estab-
lished dosing guidelines and package insert data to
support standardizing renal dosing across patient care
areas and provide a clear pathway for step-down from
IV-to-enteral therapy for agents with excellent oral
bioavailability and equivalent oral doses.
Although many established clinical benefits are
associated with such protocols, they offer good expo-
sure to newly established AMS programs across various
practice areas within the institution or health system.6,7
Once established and widely adopted, advanced dosing
and route optimization protocols may be pursued to
develop in-depth interventions. These interventions
© 2019, American Society of Health-System Pharmacists
may include dosing during continuous and acceler-
ated renal replacement therapy (CRRT and ARRT),
incorporating pharmacokinetic/pharmacodynamic
(PK/PD) data in drug dosing, prolonged (extended
or continuous) infusions of beta (β)-lactam agents,
and advanced IV-to-enteral conversions. Antimicro-
bial dosing for patients undergoing CRRT remains an
evolving area of practice.
Whereas data support certain antimicrobial dosing
regimens in CRRT, there remains a paucity of data for
many antimicrobial agents. This coupled with hetero-
geneity in study methodology, replacement fluid rates,
and CRRT filters utilized makes CRRT dosing especially
challenging for many antimicrobials.8 Despite this
heterogeneity, AMS programs are positioned to collabo-
rate with critical care pharmacists and physicians to
survey available literature and to summarize individual-
ized dosing recommendations based on replacement
rates and patient disease acuity. This again allows for
good presence and collaboration with critical care
providers, and it further cements the AMS program
credibility within the institution.
The value of PK/PD concepts in drug dosing also
continues to emerge as a major area of exploration
in clinical practice. Examples of such strategies may
include optimizing vancomycin and fluoroquinolone
dosing based on area under the concentration-time
curve (AUC) and minimum inhibitory concentration
(MIC) data, prolonged infusions of β-lactam antibiotics
based on MIC or disease acuity, and aminoglycoside
dosing to optimize peak/MIC and/or AUC/MIC ratios.
The 2009 vancomycin consensus guidelines recom-
mended vancomycin trough levels of 15-20 mg/L as
a surrogate for an AUC of 400 mg/L*hr.9 However,
contemporary data suggest trough levels of 15-20 mg/L
overexposes a majority of patients to vancomycin.10-13
Although it is prudent for pharmacists to ensure
patients’ exposure to vancomycin is adequate, it should
not be excessive. To avoid overexposure, consider 1)
prompt discontinuation of empiric vancomycin when
methicillin-resistant Staphylococcus aureus (MRSA)
infection has been excluded, including the use of MRSA
nares for patients with pneumonia when validated
locally; 2) use of AUC-based monitoring for patients on
long-term vancomycin therapy; and 3) consideration of
conservative trough targets in patients responding to

initial therapy.14-16 For example, a patient with MRSA
bacteremia without metastatic infection who clears his
or her bloodstream with rapid normalization of labo-
ratory parameters and vital signs, despite a trough of
13 mg/L, may not warrant a dose increase to target a
trough of 15-20 mg/L.
Prolonged infusions of β-lactam agents have
emerged as a useful strategy to optimize dosing without
increasing daily dose requirements of agents with short
half-lives, those significantly affected by fluid shifts, and
for patients with augmented renal clearance. Despite
consistently favorable PK and in-vitro data, clinical data
supporting extended and continuous infusion have
been conflicting, mostly due to non-randomized design
and heterogeneity in study methodologies. However,
the overall body of evidence points to favorable
outcomes in critically ill patients, those with difficult-
to-treat infections, and patients receiving continuous
infusions of β-lactam agents.17-19 Finally, AMS programs
are positioned to create treatment pathways for switch
and step-down IV-to-enteral transitions for patients
initially started on IV agents without equivalent oral
(PO) doses. These protocols incorporate clinical data
for appropriate de-escalation strategies to either similar
agents with oral equivalents or step-down transitions
(e.g., IV ceftriaxone to PO cefuroxime or other PO
cephalosporins). The latter strategies require careful
attention to appropriate indications and clinical criteria
for inclusion. Clear exclusion criteria should also be
established for unstable patients or those with infec-
tions requiring prolonged durations of IV antimicrobials.
ANTIMICROBIAL DURATION
AND TIMEOUT
Current AMS implementation guidelines from IDSA/
Society for Healthcare Epidemiology of America (SHEA)
as well as CDC and TJC suggest performing a systematic
evaluation of empiric antibiotic therapy after 48 hours of
therapy—an “antibiotic time out.”1,2,5 In essence this is a
formal re-assessment of current anti-infective therapy
hopefully in the presence of additional diagnostic data
(e.g., culture results, antibiotic susceptibilities), which
allows for therapy modification such as discontinuation,
de-escalation, and/or IV-to-PO conversion. Remarkably,
© 2019, American Society of Health-System Pharmacists
ADVANCED ANTIMICROBIAL STEWARDSHIP  5
despite recommendations from multiple organizations,
published literature supporting this oft-cited practice
remains scant and heterogeneous.20-28 IDSA suggests
a timeout and stop orders on antimicrobial therapy
(weak recommendation, based on low level evidence).5
In addition to the few studies cited by IDSA, other
published studies and conference abstracts have exam-
ined the implementation and impact of an antibiotic
timeout. Most of these studies were performed in the
intensive care unit, and substantial heterogeneity exists
with respect to the intervention tested and outcome(s)
measured. Collectively, these data suggest antibiotic
timeouts improve the appropriateness of and reduce
antibiotic use.
Development of a formal, transparent antibiotic
timeout process is laudable and appropriate given the
current mandate; however, pharmacists must recog-
nize there is no right (or wrong) way to implement an
antibiotic timeout. The premise, thus, is simple, and
we encourage pharmacists and clinicians to imple-
ment a timeout process that works well for their local
patient mix, physician practices, culture, pharmacy
structure, and electronic medical record (eMR). It may
be sensible to begin with a few high-use antibiotics
(e.g., vancomycin, broad-spectrum β-lactams). The
eMR can be used to prompt an antibiotic timeout by
pharmacists or prescribers. With the latter, the eMR
may lack the capacity to determine which prescriber(s)
should receive the timeout prompt. For example, a
timeout prompt for a critically ill patient may present
for all clinicians involved in that patient’s care. Although
this situation may be very effective, the risk may not
yield the intended results and/or engender prescriber
dissatisfaction. Alternatively, pharmacists can receive
a timeout prompt for patients within their patient care
area (e.g., specific hospital unit[s]). Stop orders have
also been proven effective at reducing antibiotic use,
but if deployed the safety mechanisms must be in place
to ensure appropriate therapy is not stopped because
such a situation could lead to patient harm.6 Whether
using a formal antibiotic timeout process and/or stop
orders, AMS clinicians should collect data and measure
the impact of such intervention(s). The paucity of data
on these interventions indicates opportunities for litera-
ture contribution and optimization of these processes.
6 PCAC - Pharmacy Competency Assessment Center
ANTIFUNGAL STEWARDSHIP
Antifungal stewardship is a lesser discussed aspect of
AMS, likely given that the majority of antimicrobials
prescribed in the inpatient setting are antibiotics.29,30
However, the antifungal armamentarium is much
smaller than the cache of antibiotics. Additionally,
antifungal resistance is increasing, limiting treatment
options. AMS pharmacists should devote resources
toward antifungal stewardship efforts, including devel-
oping restriction criteria and performing post-prescrip-
tion reviews of patients on active antifungal therapy.
Antifungal stewardship is particularly important
for critically ill and/or immunosuppressed patients as
well as patients with asymptomatic candiduria. The
former represents the majority of inpatient antifungal
use.31 Although empiric antifungal use may be prudent,
de-escalation and/or discontinuation when clinically
appropriate should also be considered. For example,
symptomatic candiduria warrants treatment but treat-
ment of asymptomatic candiduria remains common.32-34
Contemporary IDSA candidiasis guidelines outline which
patients with asymptomatic candiduria are candidates
for antifungal treatment: pregnant patients, low-birth
weight infants, and those who will undergo urologic
manipulation.35 It is worth noting that many antifungals
are expensive, and antifungal stewardship can serve to
reduce unnecessary antifungal use and contain cost.36
RAPID DIAGNOSTICS
The availability of rapid diagnostics to identify caus-
ative pathogens and key antimicrobial resistance
elements, such as mass spectrometry and molecular
assays, has revolutionized patient care and AMS. This
technology has been shown to expedite appropriate
antibiotic therapy, reduce mortality, and decrease
hospital costs.37-42 However, the IDSA guidelines on
AMS correctly point out that rapid diagnostics must be
in tandem with a robust AMS support and continuous
availability in order to be effective.5 A recent cost-
effectiveness analysis highlights how AMS support can
optimize the use of rapid diagnostics for bloodstream
infections.43 AMS pharmacists should also determine
how to participate in antimicrobial therapy optimization
following the availability of these results. Thoughtful
selection of a rapid diagnostic platform(s) based on
© 2019, American Society of Health-System Pharmacists
local patient mix and likely pathogens is crucial. The
comprehensive review of rapid diagnostics for AMS by
Bauer et al. provides additional information on rapid
diagnostics.44
ANTIMICROBIAL
CONSUMPTION TRACKING
Monitoring the progress and documenting the success
of AMS interventions require in-depth analyses of
antimicrobial consumption. Whereas consumption
metrics can vary in methodology and interpretation,
they universally require information technology (IT)
support for build, implementation, and data valida-
tion. Furthermore, benchmarking against hospitals or
healthcare systems with similar patient populations
can be challenging and lack nationally validated stan-
dards. Although several antimicrobial consumption
metrics have been evaluated in the literature, days of
therapy (DOT) and defined daily dosing (DDD) have
emerged as the most widely accepted and utilized.45,46
Notably, the CDC’s Antibiotic Utilization and Resistance
(AUR) module has been established, utilizing DOT as
the standard metric for national data collection and
benchmarking across participating U.S. hospitals.
Though voluntary, participation in the AUR module
provides financial and clinical incentives by allowing
hospitals to access benchmarking data against other
participating institutions. Furthermore, participating
hospitals receive feedback data utilizing the Standard-
ized Antimicrobial Administration Ratio (SAAR) metric
that compares observed and predicted antimicrobial
use based on calculated predictive modules developed
by CDC and applied to nationally aggregated data.47,48
Challenges facing AMS programs include initial and
ongoing IT support to accurately extract administra-
tive data versus ordering and/or purchasing data for
the pharmacy department computer and inventory
systems. Other challenges also include initial validation
and database maintenance. Notably, third-party soft-
ware programs can assist AMS programs in extracting
utilization data from the eMR but require initial valida-
tion, IT support, and capital investment for initial and
ongoing licensing. Several of these programs can also be
utilized for infection control monitoring and reporting,
and cost sharing may be available for dual-purpose
use. Finally, multi-hospital healthcare systems may be

able to benchmark antimicrobial utilization across the
system to identify areas of practice discrepancy within
similar patient populations for future interventions.
Regardless of methodology and available resources,
tracking and trending antimicrobial consumption
remains a cornerstone of AMS programs, initial devel-
opment, and ongoing assessments of outcomes.
CLOSTRIDIUM DIFFICILE–
ASSOCIATED DIARRHEA
Tied closely with AMS efforts are the usage reduction of
antibiotics most associated with C. difficile-associated
diarrhea (CDAD) infections and, consequently, a reduc-
tion in the rate of infections. National guidelines from
IDSA and SHEA recommend AMS programs implement
focused interventions to reduce the use of agents with
high risk (e.g., fluoroquinolones, clindamycin, broad-
spectrum β-lactam agents) for CDAD.49
Appropriate diagnosis of CDAD has gained interest
in recent years despite several interventions that have
shown a positive impact on reducing CDAD rates,
including personal protective equipment, terminal
patient room cleaning, and reduced antimicrobial use.
Since the introduction of polymerase chain reaction
(PCR) testing, and the rapid adoption of its role as the
gold standard test for diagnosing CDAD, several reports
have noted increasing rates of false positive results in
asymptomatic carriers without clear CDAD diagnosis
and alternative explanations for diarrhea in hospital-
ized patients (e.g., routine use of laxatives, bowel
regimens).49 In daily clinical practice, PCR testing alone
was shown to have moderate positive predictive value
depending on disease prevalence in the community and
the clinical setting.50 These observations, coupled with
heightened attention to CDAD in recent years—due to
public reporting of infection rates, potential financial
penalties, and a push for early diagnosis and isolation in
order to prevent transmission to other patients—have
led to alternative testing modalities to identify optimal
testing strategies. Two- and three-step testing proto-
cols have emerged as suitable alternatives that utilize
antigen (glutamate dehydrogenase), toxin enzyme
immunoassays, and PCR testing in a step-wise fashion to
accurately identify toxigenic strains and true infections.
This may result in increased positive predictive value
compared to PCR alone, especially when clinical labora-
© 2019, American Society of Health-System Pharmacists
ADVANCED ANTIMICROBIAL STEWARDSHIP  7
tory does not have strict criteria for testing formed and
semi-formed stool.49,50 It remains important for AMS
programs to collaborate with clinicians and laborato-
rians to ensure patients with alternative reasons for
diarrhea (e.g., laxatives) and those with formed stools
are not tested for CDAD, regardless of the local testing
methodology.
Other preventative measures to reduce rates of
CDAD in high-risk patients have focused on preserving
the diversity of healthy intestinal microbiota. Despite
their appeal, data remain conflicting regarding the role
of probiotics and active-culture dietary supplements
in primary prophylaxis of CDAD in high-risk patients
receiving broad-spectrum antimicrobial treatments.
Notably, a small body of literature suggests that enteral
vancomycin may be effective secondary prophylaxis
for CDAD in patients receiving prolonged courses of
systemic antibiotic therapy.51,52
Enteral vancomycin remains the cornerstone for
treatment of acute episodes in hospitalized patients,
while metronidazole has fallen out of favor more
recently. Contemporary IDSA guidelines recommend
enteral vancomycin dosed at 125 mg four times daily.
Fidaxomicin has gained increasing interest as a suitable
alternative to enteral vancomycin for initial and recur-
rent episodes, and data have suggested a role for fidax-
omicin in reducing risk of recurrence when compared to
enteral vancomycin.53 Prolonged pulse tapers of enteral
vancomycin or fidaxomicin should be prescribed for
patients with recurrent CDAD.49,54,55 Finally, fecal micro-
biota transplantation is recommended for patients with
multiple recurrences of CDAD who have failed antibi-
otic therapy.49 Although efforts have been undertaken
to optimize prophylactic, diagnostic, and treatment
modalities, CDAD continues to be a major challenge to
patient care with a significant morbidity and mortality
burden on healthcare systems.
β-LACTAM ALLERGY
Up to 10% of adult patients self-report a β-lactam
allergy, making this the most common type of allergy
confronted by healthcare providers.56,57 However, recent
data suggest that the actual number of patients with
a true β-lactam allergy is much lower; less than 5% of
the penicillin-allergic patients subjected to skin testing
or an oral challenge will have a positive result.57,58 Addi-
8 PCAC - Pharmacy Competency Assessment Center
tionally, 10% of penicillin skin test-positive patients per
year may lose their skin test reactivity suggesting a high
rate of penicillin tolerance in the years following a posi-
tive skin test.59 Contemporary IgE-mediated reactions
to β-lactam agents are likely to be mediated by side
chains rather than the β-lactam ring itself—making
identification of β-lactam antibiotics with similar
side chains an important aspect of protocol develop-
ment.58,60,61 Many patients will cite intolerances (e.g.,
nausea), non-specific rash, and/or a childhood history
of allergy—often relayed to them by a family member.
This situation is unfortunate given the numerous
benefits of β-lactam therapy, owning to their interac-
tions with host immunity and their ability to potentiate
both cationic host defense peptides and peptide antibi-
otics (e.g., daptomycin), all of which were summarized
nicely in a recent review by Sakoulas et al.62 Additionally,
non-β-lactam therapy is inferior to β-lactam therapy in
many situations. Use of non-β-lactam therapy compared
to β-lactam therapy is associated with an increase in
hospital length of stay, CDAD, surgical site infections,
and adverse drug events.63-65 Furthermore, use of
non-β-lactam therapy may be especially problematic
in the perioperative setting. AMS pharmacists should
collaborate with surgeons and other stakeholders to
adopt current surgical prophylaxis guidelines to use
β-lactam therapy in this setting whenever possible.66
Drug and hospitalization costs are also higher for
penicillin-allergic patients. Aztreonam is an expen-
sive agent with waning gram-negative coverage that
also lacks both gram-positive and anaerobic activity.
Developing protocols, including skin testing, to reduce
unnecessary aztreonam use can reduce drug costs.67
Even the cost of penicillin allergy testing may pale
in comparison to the cost of non-β-lactam therapy
and its associated consequences.68 National inpatient
prescribing data from 2006 to 2012 suggest that use
of non-β-lactam therapy is still high; however, fluoro-
quinolone prescribing did decrease slightly during the
study period.69 A key effort of all AMS pharmacists/AMS
programs should be to develop protocols that optimize
patients’ allergy histories and reduce the unnecessary
use of non-β-lactam therapy. Often a complete allergy
history will allow for the use of β-lactam therapy.70
Coupling a complete allergy history with an algo-
rithm to guide clinicians on the use of β-lactam therapy
© 2019, American Society of Health-System Pharmacists
in patients with history of an allergy is essential. The
literature is replete with examples of such protocols
that vary in spectrum from simply optimizing the intake
of allergy histories to inpatient penicillin skin testing—
sometimes done by pharmacists.67,71-74 Following a
comprehensive history, β-lactam allergies generally fall
into one of three hypersensitivity categories for which
decisions about β-lactam therapy can be based within
a decision algorithm: 1) Ig-E mediated then 2) severe,
non-IgE mediated, and 3) mild. Figure 1 shows one such
algorithm.74 Another option for patients with an IgE-
mediated, unknown or mild β-lactam hypersensitivity
is to perform a graded challenge: an abridged test dose
procedure in which 10% of the dose is given followed
by an observation period (e.g., 30-60 minutes). If the
patient tolerates the test dose without issue, then 90%
of the full dose, or the full dose, can be given following
the observation period.
Graded challenges can be done with IV or enteral
therapy. There is not a standard pathway for graded
challenges, but the procedure outlined by Blumenthal
et al. is comprehensive and can be used as a starting
point for AMS pharmacists.74 Decreasing reported
β-lactam allergies in the eMR and increasing β-lactam
prescribing—regardless of the intervention selected—
will represent an improvement for one’s local practice
site. All protocols start with optimizing the allergy
history often taken by nurses or medical assistants.
Collaborating with those taking allergy histories in
your facility and providing resources and education to
optimize antibiotic allergy histories is a critical first step.
It is also important to collaborate and seek the advice
of local allergy and immunology physicians. Even if not
readily available for inpatient consults, such physicians
can provide much needed guidance for local education
efforts and protocols. Additionally, collaborating with
local healthcare/pharmacy informaticists to ensure the
eMR can support appropriate allergy histories will facili-
tate optimal practices. Informaticists can help develop
reminders that direct providers to locally approved
alternatives (e.g., graded challenge, cephalosporins,
carbapenems) when non β-lactams are ordered for
patients with a β-lactam allergy listed in the profile.
In practice, healthcare professionals should review
and accurately edit erroneous allergies from the patient
chart whenever possible. However, this may not be
 ADVANCED ANTIMICROBIAL STEWARDSHIP  9

 
FIGURE 1. Example of a β-Lactam Allergy Decision Algorithm
Source: Adapted with permission from Blumenthal KG, Shenoy ES, Wolfson AR, et al. Addressing inpatient beta-lactam allergies: A 29
multihospital implementation. J Allergy Clin Immunol Pract. 2017;5(3):616-25.e7. doi: 10.1016/j.jaip.2017.02.019.
 
© 2019, American Society of Health-System Pharmacists
10 PCAC - Pharmacy Competency Assessment Center

FIGURE 1. continued
Source: Adapted with permission from Blumenthal KG, Shenoy ES, Wolfson AR, et al. Addressing inpatient beta-lactam allergies: A 30
multihospital implementation. J Allergy Clin Immunol Pract. 2017;5(3):616-25.e7. doi: 10.1016/j.jaip.2017.02.019.
 
© 2019, American Society of Health-System Pharmacists

possible in all scenarios. For example, if a patient has a
penicillin allergy but tolerates cephalosporin exposure
(e.g., ceftriaxone) then, without documented negative
penicillin skin tests, one may only be able to amend the
penicillin allergy to include that the patient tolerated
ceftriaxone. Despite being helpful, the eMR may not
recognize such amendments in the allergy history and
prescribers may still be confronted with drug-allergy
warnings when ordering future β-lactam therapy.
Educating clinicians to update the allergy history and
read it carefully—including for amendments/notes—
can help.
CONCLUSION
Pharmacists can and should engage in AMS, regardless
of their practice area. This module serves as a primer
for pharmacists seeking to engage in advanced AMS.
In addition to this module and its references, resources
and literature are freely available to aid pharmacists
in AMS.
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