Antimicrobial Stewardship: The Art of Negotiation

Antimicrobial Stewardship Programs (ASP) have been increasingly adopted by hospitals and health care systems since the Centers for Medicaid and Medicare's September 2019 mandate that acute care hospitals develop such programs [1]. More recently, the Infectious Diseases Society of America (IDSA) has initiated a Centers of Excellence designation for programs that can demonstrate that they provide a quality service [2]. The aims of ASP are to avoid antimicrobial-associated toxicity and adverse events such as Clostridioides difficile infection (CDI), ensure proper antimicrobial dosing to improve outcomes, and decrease the burgeoning levels of bacterial resistance. Actions such as de-escalation, limiting durations of therapy, and switching from intravenous to oral therapy are targeted to improve clinical outcomes and safety. Among the tools that ASP utilizes to effect change are restriction of certain antimicrobials and development of protocols and algorithms recommending antibiotic selection and/or duration based upon national guidelines [3, 4]. Institutional antibiograms, order sets with antimicrobial selection and dosing, and post-prescription review and feedback from ASP members are other methods to optimize antimicrobial use. There are often several antimicrobials with activity for a specific infection or organism. As such, there are many ways to skin the antimicrobial cat. The indication for and appropriateness of one antimicrobial agent versus another as well as the duration and dosage are often matters for debate as the quality for even strong recommendations by the IDSA is often low [5]. Algorithms and order sets developed for electronic medical records (EMR) to guide antimicrobial decisions are structured to give recommendations ranging from a single solution to a decision-tree approach for a complex problem and are based upon institutional antibiograms. The certainty in offering recommendations also applies to those made by ASP team members as well. ASP programs aim for maximum uptake of their recommendations. ASP pharmacists and clinicians, when insistent that other health care providers (HCP) follow their suggestions, may miss the larger goals of educating providers regarding current evidence and addressing outdated notions regarding antimicrobial usage. HCPs may push back based on their longstanding beliefs, not understanding contemporary resistance issues or not being familiar with newer antimicrobial regimens. This can frustrate both parties. We provide examples, based on our experience, of some strategies to illustrate how a bit of negotiation may go a long way towards the goal of recommendation acceptance and optimizing antibiotic usage. While we admit that negotiated solutions are not always optimal, the goodwill engendered by negotiation may help to gain trust and ultimately better antimicrobial usage in the long run. For new medical residents, requesting restricted antimicrobials is sometimes the first interaction they will have with an antimicrobial stewardship program. Recognizing the importance of this first impression, the ASP team member should strive to use these initial interactions to both provide education and build trust. For example, a new surgery resident requested meropenem as empiric coverage for a positive urinalysis in a patient with a history of extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli. In leading with teaching, it is important to walk the HCP through the appropriate information to assess when they reach out for approvals. In this case, does the patient have urinary tract symptoms, fever, or pyuria? Are there concerns for pyelonephritis? This offers the opportunity to remind them that asymptomatic UTIs in most instances should not be treated with antibiotics [6]. While validating that carbapenem use empirically for ESBL-producing organisms was reasonable, we were also able to discuss the potential benefits of ertapenem over meropenem in this instance and the team agreed with this choice. Recommendations regarding duration of antibiotic and possible de-escalation based on pathogen susceptibilities can also be discussed. In this case, the resident reached out a few days later for advice on narrowing therapy when susceptibility data became available. We believe that this exemplifies how building a trusting relationship is a long-term investment for an ASP program. Using evidence-based literature when negotiating with providers may help move the needle towards improved practices. Antimicrobials have a long history of use prior to the implementation of randomized controlled trials. Dogmatic practices in infectious diseases are a prominent topic of conversation, requiring careful presentation of evidence to challenge those beliefs and assertions [7]. Many providers may choose to continue ceftriaxone for various gram-negative and gram-positive infections given its convenient daily dosing when a narrower spectrum antimicrobial such as cefazolin may be preferred to decrease the risk of CDI and the emergence of resistance by other bacteria [8, 9]. This leads the conversation towards matters of mutual interest: what is best for the patient. For example, an infection due to susceptible Enterobacterales, providing relevant literature may move providers towards a de-escalation mindset. We have successfully de-escalated ceftriaxone to cefazolin in many patients with susceptible E. coli bacteremia from a urinary source by directing the medical team to our EMR ASP generated clinical pearl “Can we de-escalate beyond Ceftriaxone.” The pearl reviews literature identifying a significantly higher risk of CDI [9-14] and increased risk of colonization or infection with extended-spectrum-beta-lactamases (ESBL) or Amp-C producing gram-negative organisms [15-17]. Another tactic of negotiation follows the real-world application of salary negotiation: aim high and leave room for an acceptable outcome in the middle. For example, our ASP, through the Antimicrobial Stewardship EMR communication portal, contacted one of the infectious diseases attendings to consider transitioning their patient with uncomplicated K. pneumoniae bacteremia from a urinary source to oral antibiotics as the patient had received 5 days of intravenous antibiotics and was clinically stable. In this example, two stewardship interventions were suggested: transitioning to a narrower oral antibiotic after at least 3 days of intravenous (IV) antibiotics and limiting the total duration to 7 days. The attending's preference had been to wait until discharge to continue IV therapy and to give 14 days of therapy. We were able to negotiate changes in therapy by providing the supporting literature [18, 19]. Although IV therapy was continued, the antibiotic selection was narrowed and duration shortened. Attempt to find ways to be seen as helpful to provider teams and not simply be perceived as a hindrance for getting antibiotic approval. This includes, among other things, reaching out to teams that have not asked for approval for restricted antimicrobials and making suggestions regarding better antimicrobial choices. An example that resonates is using the positive blood culture list built into our EMR as an opportunity to reach out to HCPs. Through discussion of the culture results, the ASP team can introduce enterprise guidelines for empiric treatment based upon cultured organisms and rapid resistance determinations. Recently, a patient's blood culture was positive for Enterococcus faecalis. The patient was empirically started on IV vancomycin. The ASP team messaged the medical resident to switch to ampicillin given the higher susceptibility rates of this organism to ampicillin compared to vancomycin [20] and improved the side effect profile. By establishing that first contact, the treatment team asked for further advice about broader empiric coverage based on a suspected gastrointestinal source. After some discussion, ampicillin-sulbactam was selected. This antimicrobial choice was narrower than the often-prescribed piperacillin-tazobactam and avoided the use of vancomycin. While most antimicrobial stewardship interventions support a “less is more” approach, the evolving antimicrobial resistance landscape sometimes requires interventions that broaden or intensify antimicrobial coverage. ASP teams may gain trust and be seen as problem solvers when they provide recommendations noting that the narrower coverage does not have sufficient activity against cultured pathogens or may lead to greater resistance. For example, an intensive care unit medical resident requested cefiderocol for a patient with difficult-to-treat Pseudomonas aeruginosa pneumonia who had been prescribed meropenem. The patient had a history of P. aeruginosa that was resistant to carbapenems and ceftazidime-avibactam. We educated the resident on the differences in spectrum of activity, toxicity profiles, and tissue penetration between cefiderocol, ceftolozane-tazobactam, and polymyxin B, as well as the role of adjunctive aminoglycosides. This approach resulted in the selection of a more appropriate agent. For some, this editorial may prompt to think “so, what else is new?” Many ASP members have learned the importance of the art of negotiation for the success of their programs. However, some HCP have either preconceived notions or minimal exposure to stewardship programs, or perhaps large egos, such that they want to do what they have always done and push back against recommendations. This article is simply a reminder to infectious diseases clinical pharmacists and ASP physicians that negotiation is the better part of valor and, in the long run, fosters trusting relationships and improves adherence to ASP recommendations. No AI tools were used in the drafting of this manuscript, tables, or figures. The authors declare no conflicts of interest.