Antimicrobial stewardship 2大戦略
prospective audit and feedback (PAF)とPreauthorization
Preauthorization – In programs that utilize preauthorization, approval is required (by an infectious disease physician or pharmacist) before certain antibiotic agents may be administered. In some programs, the availability of certain antibiotics for specific indications is limited, and some antibiotics may be rendered to a non-formulary status. This approach provides an opportunity to optimize the initial choice of antibiotic therapy as well as an opportunity to educate individual prescribers about appropriate antibiotic use, which may affect subsequent use. Advantages and disadvantages of preauthorization are summarized in the Table and discussed further below.
Preauthorization — Preauthorization is defined above. Advantages and disadvantages of preauthorization are summarized in the Table.
Preauthorization has been shown to be effective in reducing antibiotic use and cost. Even in programs with high rates of antibiotic approval, preauthorization has been associated with decreased utilization of targeted antibiotics, suggesting preauthorization is also a passive barrier to prescribing. The impact of preauthorization on antibiotic resistance is mixed; some studies have demonstrated an association with improved antibiotic susceptibilities, while others have shown no effect.
Preauthorization programs are often associated with a perceived imposition on prescriber autonomy in clinical decision-making. Verbal misrepresentation of relevant clinical data may lead to inappropriate recommendations, so direct chart review is needed. Preauthorization is time and labor intensive and requires around-the-clock coverage. Some programs with limited resources allow a first dose of antibiotics in off-hours, with stewardship program review the following day. Other programs focus preauthorization resources on certain antibiotics that are misused commonly. Preauthorization can result in unintended increased use of other, nonrestricted antibiotics ("squeezing the balloon"), mitigating the intervention's effect on overall antibiotic use. Thus, it is reasonable to monitor all antibiotic use after implementation of formulary restriction.