Assessing Pharmacy Students’ and Preceptors’ Understanding of and Exposure to Antimicrobial Stewardship Practices on Introductory Pharmacy Practice Experiences

Antimicrobial stewardship (AMS) is commonly employed, and may be required, in multiple healthcare settings, with pharmacists playing an integral role in developing and conducting AMS techniques. Despite its prevalence, AMS is minimally taught in pharmacy school curricula. In order to increase student and preceptor understanding and application of AMS techniques, the Medical College of Wisconsin School of Pharmacy required introductory pharmacy practice students to complete three checklists and reflections of AMS techniques observed at three different practice settings: inpatient, ambulatory, and community (retail) pharmacy. Student and preceptor understanding and application of AMS techniques were then assessed via voluntary survey. Survey response rates were 43% for pharmacy students, while preceptor response rates were 27%. Student understanding and application of AMS techniques increased after completion of the AMS checklist, with the largest magnitude of change seen with antibiotic selection recommendations and guideline and policy development. Preceptor understanding was minimally impacted by the activity; however, an increase in understanding was seen for allergy assessments, antibiotic time-outs, and vaccine assessments and recommendations. AMS is an important component of pharmacy practice today. Implementation of a checklist and reflection activity within experiential education increases perceived student understanding and application of relevant AMS techniques.


Introduction
Antimicrobial stewardship (AMS) is commonly seen in many facets of healthcare, and pharmacists are important members of an antimicrobial stewardship team [1]. Since 1 January 2017, The Joint Commission (TJC) has required all acute care facilities to comply with the antimicrobial stewardship medication management standard [1]. Additionally, on 1 January 2020, TJC also implemented AMS requirements for accredited ambulatory care centers [2]. Despite these widespread requirements for pharmacy practice, no consensus exists for AMS education in pharmacy education. The American College of Clinical Pharmacy published a curriculum toolkit in 2016 identifying AMS as one of 24 Tier-2 infectious disease competencies, recommending students receive education and training on AMS but suggesting additional postgraduate training may be required [3]. AMS has since been removed from the 2019 version of the toolkit [4]. to didactic instruction, introductory pharmacy practice experiences (IPPEs) are intentionally woven into the first two years. Students complete a total of seven IPPE experiences; each IPPE experience is 10 weeks in duration with the student attending the practice site every Friday for a minimum of 8 h per day. Students are required to complete two community pharmacy rotations (one at a retail chain location and the other at a non-chain location), two hospital pharmacy rotations (one at Froedtert Hospital, an academic medical center, and the other at a community hospital), two elective rotations, and one interprofessional rotation. Elective rotations may include, but are not limited to, ambulatory care centers, specialty pharmacy, long-term care pharmacy, and inpatient specialty practice such as infectious diseases or oncology. Interprofessional rotations primarily occur in ambulatory or inpatient practice settings, and students are precepted by a non-pharmacist healthcare professional during this rotation.
Didactic courses are delivered in an integrated fashion, with pharmacology, medicinal chemistry, and therapeutics enveloped into the same course. Pharmacy students complete two, 10-week, 5-credit courses dedicated to infectious diseases, which occur during the second semester of their first academic year. AMS is formally taught during a 2-h session within the first infectious diseases course, with AMS topics then integrated throughout the remainder of the infectious diseases curriculum. In preparation for the formal 2-h AMS didactic instruction, students are required to read the executive summary of the Infectious Diseases Society of America's Guidelines for Implementing an Antimicrobial Stewardship Program [10]. In the classroom, students receive a short presentation outlining the rationale for AMS and are then broken into groups and assigned an AMS technique to research in detail. The groups then develop slides via a template provided that describe their assigned strategy, and finally present their strategy to the class at large. An AMS pharmacist faculty member is present to add or clarify necessary information.
In order to connect this didactic learning with clinical practice, students are also assigned three AMS activities during their IPPE rotations. Students must assess AMS strategies utilized at three different practice settings: inpatient, ambulatory clinic, and community (retail) pharmacy. All students utilize standardized checklists provided by the Centers for Disease Control and Prevention (CDC) for the inpatient [11] and ambulatory rotations [12], and a faculty-developed survey for the community rotation, with components that align with the standardized CDC surveys but that are modified for community/retail practice, as a standardized CDC checklist for the community setting does not exist (Appendix A). After completing each checklist, the student must also compose a 500-word reflection that describes what additional AMS strategy could be implemented by that clinical practice site. This activity is assessed by MCW faculty and not by preceptors. Students were encouraged to discuss this activity with preceptors during completion, but preceptor oversight and involvement is not required. Additionally, preceptors are able to view the activity submission within the learning management software utilized for experiential education student evaluation.
In February 2020, a survey housed within Qualtrics was sent via email to all current MCW School of Pharmacy students in the classes of 2020, 2021, and 2022, in order to analyze the impact of the AMS IPPE educational activity as a means of curricular analysis and development. Additionally, Qualtrics was used to administer a survey to all clinical preceptors who had precepted an IPPE student in the same three classes, to evaluate the indirect impact on preceptors by students completing this activity at their site. Survey questions evaluated the impact of assessing AMS techniques currently employed in clinical practice sites via a checklist paired with a reflection activity on student and preceptor understanding of AMS techniques. Additionally, students and preceptors assessed opportunities for AMS practice expansion at clinical sites. The surveys were designed by experiential education and AMS faculty members and were reviewed by the MCW School of Pharmacy Research Committee and Institutional Review Board. The student and preceptor surveys can be found in Appendix ??.
Survey responses were anonymous and de-identified data were analyzed. Descriptive statistics will be used to describe data. Student t-test will be used for continuous, normally distributed data. A p-value < 0.05 will be considered statistically significant.

Pharmacy Student Survey
A total of 60 of 139 eligible students completed the AMS student survey, resulting in a 43% completion rate. Twenty-eight percent of respondents were in the class of 2020, 43% in the class of 2021, and 28% in the class of 2022. Hospital checklists and reflections were completed the most frequently, with 42% of students reporting completion; 21% of students completed the activity in the ambulatory environment, and 37% of students completed the activity in the community setting.
When asked the likelihood of implementing AMS techniques in their future career, only one student thought doing so would be highly unlikely. Fourteen students (33%) felt they were highly likely to implement AMS techniques during their career, 21 students (50%) felt they were likely to implement, and 6 (14%) were unsure.
Students' understanding of all AMS techniques increased after completion of the AMS checklist, with the largest magnitude of change seen with antibiotic selection recommendations and guideline and policy development (see Figure 1). In addition, after completion of the reflection component of the activity, 4 (10%) and 26 (65%) students reported that their understanding of AMS practices was greatly enhanced and somewhat enhanced, respectively. Survey responses were anonymous and de-identified data were analyzed. Descriptive statistics will be used to describe data. Student t-test will be used for continuous, normally distributed data. A p-value < 0.05 will be considered statistically significant.

Pharmacy Student Survey
A total of 60 of 139 eligible students completed the AMS student survey, resulting in a 43% completion rate. Twenty-eight percent of respondents were in the class of 2020, 43% in the class of 2021, and 28% in the class of 2022. Hospital checklists and reflections were completed the most frequently, with 42% of students reporting completion; 21% of students completed the activity in the ambulatory environment, and 37% of students completed the activity in the community setting.
When asked the likelihood of implementing AMS techniques in their future career, only one student thought doing so would be highly unlikely. Fourteen students (33%) felt they were highly likely to implement AMS techniques during their career, 21 students (50%) felt they were likely to implement, and 6 (14%) were unsure.
Students' understanding of all AMS techniques increased after completion of the AMS checklist, with the largest magnitude of change seen with antibiotic selection recommendations and guideline and policy development (see Figure 1). In addition, after completion of the reflection component of the activity, 4 (10%) and 26 (65%) students reported that their understanding of AMS practices was greatly enhanced and somewhat enhanced, respectively.   When specifically analyzing data from students on an inpatient rotation, 70.6% of respondents reported observing AMS practices daily. The majority of AMS techniques were already implemented at inpatient sites, however students responded antibiotic time-outs and prospective audit and feedback could be easily implemented at sites where these practices were not in place (Figure 2a).
AMS techniques were not as prevalent in an ambulatory care setting, with 39% of students observing them daily, 39% of students observing them once per month, 17% observing once per rotation, and one student never observing AMS techniques in practice. While ambulatory sites did demonstrate implementation of multiple AMS techniques, students felt sites could also implement dosing optimization strategies, order sets, IV to PO interchange, and prospective audit and feedback ( Figure 2b).
Routine observation of AMS techniques in a community setting was varied, with 31% of students observing them daily, 27% observing them once per month, 31% observing once per rotation, and 12% never observing them. Patient education and allergy assessments were the most common techniques used in this setting ( Figure 2c). Students identified several techniques that could be implemented in community practice, including dosing optimization, duration of therapy assessments, guideline and policy development, and tracking of antibiotic use. Students also identified that some techniques would be difficult to implement in this setting, namely antibiotic time-outs, antibiotic selection recommendations, and antimicrobial restrictions.
In all, 60%, 33%, and 51% of students reported discussing this activity with their preceptor on the inpatient, ambulatory, and community IPPE rotations, respectively. When specifically analyzing data from students on an inpatient rotation, 70.6% of respondents reported observing AMS practices daily. The majority of AMS techniques were already implemented at inpatient sites, however students responded antibiotic time-outs and prospective audit and feedback could be easily implemented at sites where these practices were not in place ( Figure 2a).
AMS techniques were not as prevalent in an ambulatory care setting, with 39% of students observing them daily, 39% of students observing them once per month, 17% observing once per rotation, and one student never observing AMS techniques in practice. While ambulatory sites did demonstrate implementation of multiple AMS techniques, students felt sites could also implement dosing optimization strategies, order sets, IV to PO interchange, and prospective audit and feedback ( Figure 2b).
Routine observation of AMS techniques in a community setting was varied, with 31% of students observing them daily, 27% observing them once per month, 31% observing once per rotation, and 12% never observing them. Patient education and allergy assessments were the most common techniques used in this setting ( Figure 2c). Students identified several techniques that could be implemented in community practice, including dosing optimization, duration of therapy assessments, guideline and policy development, and tracking of antibiotic use. Students also identified that some techniques would be difficult to implement in this setting, namely antibiotic time-outs, antibiotic selection recommendations, and antimicrobial restrictions. In all, 60%, 33%, and 51% of students reported discussing this activity with their preceptor on the inpatient, ambulatory, and community IPPE rotations, respectively. Antimicrobial stewardship techniques observed as currently employed, not employed but could be implemented, and not employed but would be hard to implement at (a) inpatient pharmacy sites, (b) ambulatory clinic sites, and (c) community pharmacy sites, as described by pharmacy students. DOT: duration of therapy; IV: intravenous; PO: oral; PA&F: prospective audit and feedback; AMS: antimicrobial stewardship.

Preceptor Survey
Overall, 63 of 236 pharmacist preceptors completed the AMS survey, demonstrating a 27% completion rate. The majority of respondents were inpatient pharmacists, followed by community pharmacists and ambulatory pharmacists at 46%, 40%, and 8%, respectively, which mirrors the practice sites where students reported completing the AMS activities. Forty percent of respondents reported receiving didactic instruction on antimicrobial stewardship in pharmacy school. While only 28% of respondents discussed this IPPE activity with their students, 52% were interested in working on this activity with their IPPE student.
The IPPE AMS activity had minimal impact on pharmacists' understanding of antimicrobial stewardship practices (Figure 3). Of the 16 practices assessed, only three demonstrated increased understanding after the activity, including allergy assessments, antibiotic time-outs, and assessing and recommending vaccinations.

Preceptor Survey
Overall, 63 of 236 pharmacist preceptors completed the AMS survey, demonstrating a 27% completion rate. The majority of respondents were inpatient pharmacists, followed by community pharmacists and ambulatory pharmacists at 46%, 40%, and 8%, respectively, which mirrors the practice sites where students reported completing the AMS activities. Forty percent of respondents reported receiving didactic instruction on antimicrobial stewardship in pharmacy school. While only 28% of respondents discussed this IPPE activity with their students, 52% were interested in working on this activity with their IPPE student.
The IPPE AMS activity had minimal impact on pharmacists' understanding of antimicrobial stewardship practices (Figure 3). Of the 16 practices assessed, only three demonstrated increased understanding after the activity, including allergy assessments, antibiotic time-outs, and assessing and recommending vaccinations. When asked which AMS technique preceptors they were likely to implement that was not currently employed, the most common responses were duration of therapy adjustments, guideline and policy development, prescriber education, and assessing and recommending vaccinations ( Figure 4). When asked which AMS technique preceptors they were likely to implement that was not currently employed, the most common responses were duration of therapy adjustments, guideline and policy development, prescriber education, and assessing and recommending vaccinations (Figure 4).

Discussion
Our results demonstrate a required AMS checklist and reflection activity during IPPE rotations significantly increases perceived student understanding of AMS techniques. Students had the greatest exposure to AMS during an inpatient rotation, where these practices were commonly integrated into daily practice. Preceptor survey results indicate a slight trend toward increased understanding of select techniques; however, knowledge was largely unchanged by the activity. The benefit of this activity to preceptors may be underestimated, as not all students discussed this activity with their preceptors. Moving forward, preceptors will be trained on this activity and their involvement will be encouraged, which may help to promote the implementation of AMS techniques at clinical practice sites.
Previous studies have evaluated various instructional methods for AMS in schools of pharmacy; however, none of them have evaluated a required checklist and reflection activity incorporated into IPPE rotation experiences. The University of California, San Francisco, implemented a required didactic AMS learning activity incorporating an online educational module and interprofessional workshop with second-year medical students and third-year pharmacy students [13]. The educational module required students to individually review a branching-logic case and answer associated questions. Following the individual component, students were divided into small interprofessional groups to re-work the first case previously provided online plus an additional case; a large group discussion followed. Students' knowledge of and attitudes toward AMS were assessed via survey before and after the educational activity. A total of 84.5% and 92.7% of students, respectively, agreed or strongly agreed that the online module and workshop were valuable learning experiences. Survey results showed the curriculum significantly prepared them to describe the role of various professions in appropriate antibiotic use, communicate and engage with the interprofessional team, and to describe collaborative approaches to antibiotic use. This study demonstrated that students developed skills necessary for conducting AMS techniques but did not specifically assess students' understanding of various AMS techniques as our study did.

Discussion
Our results demonstrate a required AMS checklist and reflection activity during IPPE rotations significantly increases perceived student understanding of AMS techniques. Students had the greatest exposure to AMS during an inpatient rotation, where these practices were commonly integrated into daily practice. Preceptor survey results indicate a slight trend toward increased understanding of select techniques; however, knowledge was largely unchanged by the activity. The benefit of this activity to preceptors may be underestimated, as not all students discussed this activity with their preceptors. Moving forward, preceptors will be trained on this activity and their involvement will be encouraged, which may help to promote the implementation of AMS techniques at clinical practice sites.
Previous studies have evaluated various instructional methods for AMS in schools of pharmacy; however, none of them have evaluated a required checklist and reflection activity incorporated into IPPE rotation experiences. The University of California, San Francisco, implemented a required didactic AMS learning activity incorporating an online educational module and interprofessional workshop with second-year medical students and third-year pharmacy students [13]. The educational module required students to individually review a branching-logic case and answer associated questions. Following the individual component, students were divided into small interprofessional groups to re-work the first case previously provided online plus an additional case; a large group discussion followed. Students' knowledge of and attitudes toward AMS were assessed via survey before and after the educational activity. A total of 84.5% and 92.7% of students, respectively, agreed or strongly agreed that the online module and workshop were valuable learning experiences. Survey results showed the curriculum significantly prepared them to describe the role of various professions in appropriate antibiotic use, communicate and engage with the interprofessional team, and to describe collaborative approaches to antibiotic use. This study demonstrated that students developed skills necessary for conducting AMS techniques but did not specifically assess students' understanding of various AMS techniques as our study did. While studies have not assessed the incorporation of IPPE students into AMS practice on experiential rotations, APPE students have been utilized to conduct prospective audit and feedback during elective experiential rotations. Benson described his experience incorporating APPE students into prospective audit and feedback activities at a long-term-care hospital [14]. Under the supervision of an infectious diseases pharmacist, APPE students reviewed patient health records to identify opportunities for antimicrobial dose optimization, appropriate durations of therapy, and antibiotic use in the setting of allergies. APPE students also monitored patient response to antibiotic therapy and evaluated microbiologic data to ensure antibiotic use was optimized. Interventions were discussed with the infectious diseases pharmacist preceptor and then presented to the prescriber by the APPE student. While an analysis of student learning was not described in this study, reduced antimicrobial costs per patient day were seen after incorporation of APPE students ($75.37 ± $11.85 prior to implementation, and $64.13 ± $13.27 after implementation, p = 0.022). Laibel and colleagues described the integration of APPE students into prospective audit and feedback activities on the medical/surgical floor of an acute care hospital [15]. Students assessed antimicrobial therapy and discussed recommendations with an infectious diseases physician three times per week. The infectious diseases physician then presented those recommendations to the primary team. Over two years, a total of 554 recommendations were made with a 68.4% acceptance rate. The majority of interventions resulted in antimicrobial agent changes or discontinuation. Neither study assessed student understanding of AMS techniques at large or assessment of antimicrobial stewardship activities seen in practice, as our study did. Additionally, these experiential education experiences were only available to students who elected to complete these particular rotations and not to the entire pharmacy class. While our checklist and reflection activity did not actively engage students in practicing AMS techniques, it provided a valuable framework to all introductory pharmacy students by expanding understanding and evaluation of AMS techniques within various practice sites. This framework will assist students when they progress to APPE rotations and are actively involved in practicing AMS strategies. Additionally, our activity exposed students to AMS practices in a variety of practice settings, while literature has primarily described student AMS experiential learning in an acute care environment.
There are several limitations to our study. First, this study is based on survey responses and is dependent on the opinions and perceptions of those that completed the survey. Students and preceptors who already have an interest in or commitment to antimicrobial stewardship may have been more likely to complete the survey, and our relatively low response rate could have resulted in selection bias. There also may have been a tendency for students to overestimate their perceived understanding, as they presume understanding should increase after an educational activity; this phenomenon was not seen in the preceptor responses. Since the majority of preceptor respondents practiced within an acute care environment, they likely conduct AMS techniques in daily practice and this activity likely did not change their understanding. Additionally, the survey was not validated, it was simply created for curricular analysis and development. Our IPPE students typically complete rotations within 60 miles of the school, and the survey results may be influenced by practice in the greater Milwaukee area. All students complete one hospital IPPE rotation at Froedtert Hospital, the academic medical center in Milwaukee, and survey results could be skewed to reflect student experiences at that site, as the majority of students reported completing the acute care activity within the survey. Froedtert Hospital has a robust AMS program, which allowed students to observe most of these techniques in practice.

Conclusions
AMS, while an integral component of clinical practice today, is inconsistently taught during pharmacy school, with some schools incorporating AMS into the required didactic curriculum and others incorporating it into the elective experiential education curriculum [7,8,[13][14][15]. National guidance for how to incorporate AMS education into schools of pharmacy does not exist [4], and schools incorporating this education typically have a faculty member who practices in infectious diseases [7]. This study demonstrates didactic AMS instruction coupled with a required application activity during IPPE rotations can increase perceived understanding and application of AMS techniques by pharmacy students in inpatient, ambulatory, and community practice. This foundational understanding provides a strong framework to build upon when conducting AMS in clinical practice as students progress through the APPE curriculum, postgraduate training, and into the workforce, where AMS will be employed. Future research should be completed on the impact of required AMS training during APPE rotations, analyzing both student's understanding and the clinical implications of student participation in a variety of AMS techniques. The impact of required AMS education in didactic and experiential education on future pharmacist involvement with AMS practices should also be analyzed. Acknowledgments: The authors would like to acknowledge Karen MacKinnon, for her incorporation of this activity into the experiential education curriculum.

Conflicts of Interest:
The authors declare no conflict of interest.

Commitment
Does the facility or organization demonstrate dedication to and accountability for optimizing antibiotic prescribing and patient safety related to antibiotics?
Yes No Select all that apply: Have leadership that focuses on optimizing antibiotic therapy Display public commitments in support of antibiotic stewardship Other ____

Pharmacy Practice
What do practitioners at your site evaluate when presented with an antibiotic prescription? (select all that apply) Duration of therapy adjustments c.
Allergy assessments d.
Antibiotic selection recommendations e.
Guideline/policy development f.
Order set implementation g.
IV to PO interchange h.
Antibiotic time-out i.
Computerized alerts j.
Pharmacist education k.
Patient education Duration of therapy adjustments c.
Allergy assessments d.
Antibiotic selection recommendations e.
Guideline/policy development f.
Order set implementation g.
IV to PO interchange h.
Computerized alerts j.
Pharmacist education k.
Patient education l.
Prescriber education m.
Assessing and recommending vaccinations n.
Tracking antibiotic use o.
Prospective audit and feedback p.
Antimicrobial restriction

Comments
Definitions: (a) Introductory pharmacy practice experience (IPPE): A rotation pharmacy students complete during the timeframe of didactic instruction in order to introduce students to the practice of pharmacy in various settings. At MCW School of Pharmacy, students complete seven distinct IPPE rotations. Each IPPE rotation totals a minimum of 80 h and has been intentionally incorporated into the curriculum to occur every Friday for a minimum of 8 h per day for 10 consecutive weeks. (b) Dosing optimization [7]: Utilizing the pharmacokinetic and pharmacodynamic properties of a drug as well as individual patient characteristics to determine optimal antibiotic dosing. Examples include: renal dose adjustment, dose adjustment for indication, extended infusion beta-lactams, pharmacokinetic dosing of vancomycin/aminoglycosides, etc. (c) Duration of therapy adjustments [7]: Prolonging or shortening antibiotic duration of therapy based on guideline recommendations and/or patient-specific factors and response to antibiotic therapy. (d) Allergy assessments [7]: Defining an antibiotic allergy to include reaction type, onset after ingestion/administration, how allergic reaction was treated, how long ago reaction occurred, etc. and documenting information. Could also include conducting penicillin skin testing. (e) Antibiotic selection recommendations [7]: Initial, de-escalation, or alternative antibiotic therapy recommendations made based on guidelines, patient-specific factors, and/or local susceptibility data (f) Guideline/policy development [7]: Developing institutional or organizational practices for antibiotic use that take into account national guidelines, patient-specific characteristics, and local susceptibility data. (g) Order set implementation [7]: An electronic or paper tool that guides institutional or organizational practice for antibiotic use. The order set can assist with antibiotic selection, dosing, route, and duration of therapy. (h) IV to PO interchange [7]: An assessment of ability for a patient to tolerate enteral antibiotics. If enteral antibiotics can be utilized, intervention to oral therapy from intravenous therapy should be made. (i) Antibiotic time-out [7]: A routine, structured review of antimicrobial therapy at a set time (usually 48-72 h after initiation of empiric antimicrobial therapy). Duration of therapy adjustments c.
Allergy assessments d.
Antibiotic selection recommendations e.
Guideline/policy development f.
Order set implementation g.
IV to PO interchange h.
Computerized alerts j.
Pharmacist education k.
Patient education l.
Prescriber education m.
Assessing and recommending vaccinations n.
Tracking antibiotic use o.
Prospective audit and feedback p.
Antimicrobial restriction

Comments (Free Text)
Definitions: (a) Introductory pharmacy practice experience (IPPE): A rotation pharmacy students complete during the timeframe of didactic instruction in order to introduce students to the practice of pharmacy in various settings. At MCW School of Pharmacy, students complete seven distinct IPPE rotations. Each IPPE rotation totals a minimum of 80 h and has been intentionally incorporated into the curriculum to occur every Friday for a minimum of 8 h per day for 10 consecutive weeks. (b) Dosing optimization [7]: Utilizing the pharmacokinetic and pharmacodynamic properties of a drug as well as individual patient characteristics to determine optimal antibiotic dosing. Examples include: renal dose adjustment, dose adjustment for indication, extended infusion beta-lactams, pharmacokinetic dosing of vancomycin/aminoglycosides, etc. (c) Duration of therapy adjustments [7]: Prolonging or shortening antibiotic duration of therapy based on guideline recommendations and/or patient-specific factors and response to antibiotic therapy. (d) Allergy assessments [7]: Defining an antibiotic allergy to include reaction type, onset after ingestion/administration, how allergic reaction was treated, how long ago reaction occurred, etc. and documenting information. Could also include conducting penicillin skin testing. (e) Antibiotic selection recommendations [7]: Initial, de-escalation, or alternative antibiotic therapy recommendations made based on guidelines, patient-specific factors, and/or local susceptibility data (f) Guideline/policy development [7]: Developing institutional or organizational practices for antibiotic use that take into account national guidelines, patient-specific characteristics, and local susceptibility data. (g) Order set implementation [7]: An electronic or paper tool that guides institutional or organizational practice for antibiotic use. The order set can assist with antibiotic selection, dosing, route, and duration of therapy.
(h) IV to PO interchange [7]: An assessment of ability for a patient to tolerate enteral antibiotics. If enteral antibiotics can be utilized, intervention to oral therapy from intravenous therapy should be made. (i) Antibiotic time-out [7]: A routine, structured review of antimicrobial therapy at a set time (usually 48-72 h after initiation of empiric antimicrobial therapy). (j) Computerized alerts [7]: Notifications of potential interactions or misuse of antibiotics that are displayed to prescribers at the time of antibiotic ordering. (k) Pharmacist education [7]: Educating pharmacists on antimicrobial stewardship techniques, resistance, and antimicrobial best practices. Education could be either active (e.g., direct, real-time feedback) or passive (e.g., email). (l) Patient education [7]: Educating patients on the appropriate use of antimicrobials, antimicrobial resistance, the importance of antimicrobial stewardship, the difference between viral and bacterial infections, etc. Education could be either active (e.g., direct, real-time feedback) or passive (e.g., email). (m) Prescriber education [7]: Educating prescribers on the appropriate use of antimicrobials, antimicrobial resistance, the importance of antimicrobial stewardship, the difference between viral and bacterial infections, etc. Education could be either active (e.g., direct, real-time feedback or as prospective audit and feedback) or passive (e.g., email). (n) Assessing and recommending vaccinations: Analyzing patient data to determine vaccine eligibility and recommending immunizations for patients. Could involve vaccine administration. (o) Tracking antibiotic use [7]: Any system in place that allows for antibiotic use or prescriptions to be quantified. (p) Prospective audit and feedback [7]: Structured review of antibiotic utilization, often conducted after antibiotics have already been prescribed and possibly administered. (q) Antimicrobial restriction [7]: Limiting use of antimicrobials for specific indications, or requiring approval by an infectious diseases practitioner before prescription of that antimicrobial can occur.