11/22/2016. Antimicrobial Stewardship Update Disclosures. Outline. No conflicts of interest to disclose

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1 Antimicrobial Stewardship Update 2016 APIC-CI Conference November 17 th, 2016 Jay R. McDonald, MD Chief, ID Section VA St. Louis Health Care System Assistant Professor of medicine Washington University School of Medicine Disclosures No conflicts of interest to disclose Outline What is antimicrobial stewardship? Why now? New regulatory requirements Possible elements of a stewardship program 1

2 Antimicrobial stewardship Definition: Coordinated interventions designed to improve and measure the appropriate use of [antibiotic] agents by promoting the selection of the optimal drug regimen including dosing, duration of therapy, and route of administration (Infect Control Hosp Epidemiol 2012;33:322-7) Antimicrobial stewardship has been around for a long time, but new concerns about rising antimicrobial resistance and limited pipeline of new antibiotics to deal with this problem has brought stewardship to the forefront. Antimicrobial stewardship can help prevent the development and spread of MDROs, reduce unnecessary drug use and costs associated with expensive, broad-spectrum therapies used to treat HAIs, and improve patient safety. Antimicrobial use More than half of hospitalized patients receive an antibiotic Up to 50% of antibiotic prescribing is inappropriate Antibiotic selection Route Duration Dosing Inpatient and outpatient Factors driving inappropriate prescribing Lack of knowledge Fear of litigation Patient expectations Balance between interests of the individual patient and interests of society as a whole Consequences of excess and inappropriate antibiotic use Antibiotics are responsible for 1 in 5 ER visits for adverse drug events Resistant pathogens cause over 2 million illnesses and 23,000 deaths in the US every year There are 250,000 Clostridium difficile infections (CDI) and 14,000 CDI deaths in the US every year Excess antibiotic use is estimated to cause about $1 billion in excess medical costs per year in the US Antibiotic use promotes antimicrobial resistance Dellit TH, et al. Clin Infect Dis 2007;44: Shehab N, et al. Clin Infect Dis 2008;47(6): Fridkin S. et al. MMWR 2014;63(09):

3 Goals of antimicrobial stewardship Optimize clinical outcomes Minimize unintended consequences Adverse events and toxicities Unintended consequences (CDI) Emergence of resistance Improve cost-effectiveness Drug costs Shorten hospital stays A study from University of Maryland demonstrated a cost savings to the health system of $17 million over 8 years directly attributable to the antimicrobial stewardship program CDC: Antibiotic Resistance Threats in the United States URL Antimicrobial Stewardship Team Multidisciplinary Approach Hospital Administration Inpatient Physician/ Hospitalist Quality & Safety Management Information System Specialist Antimicrobial Stewardship Team ID Physician ID Pharmacist Primary Medical Provider Hospital Epidemiologist Infection Prevention and Control Microbiology Dellit TH, et al. Clin Infect Dis. 2007; 44: Stewardship team State-of-the-art stewardship requires: Commitment by facility of resources Participant time Information technology resources Microbiology lab resources Support for initiatives IDSA recommends that stewardship team be led by an ID physician with training in AS. Participation by Infection Prevention, Pharmacy, and Microbiology Lab is absolutely essential Administrative structure within an institutional organization chart can vary national VA directive mandates local protocol describing reporting to standing committees (i.e. Infection Control Committee, Pharmacy and Therapeutics, Medical Executive Board, etc) Input from ICC to annual ASP evaluation 3

4 Regulatory/administrative milestones VHA Directive 1031: published January 2014 Requires written stewardship policy Development of team with provider and pharmacy champions Annual evaluation of the program In June 2015, White House forum on Antibiotic Stewardship was held In April 2016, IDSA and SHEA published a joint guideline titled Implementing an Antibiotic Stewardship Program: Guidelines by the IDSA and SHEA in Clinical Infectious Disease (DOI: /cid/ciw118) In July 2016, Healthcare Infection Control Practices Advisory Committee (HICPAC) provided guidance for the first time to professional organizations on incorporating antibiotic stewardship principles into treatment guidelines In mid-2016, JCAHO announced a new Medication Management (MM) standard, MM : The hospital has an antimicrobial stewardship program based on current scientific literature JCAHO recommends inclusion of ID physician, Infection Preventionist, Pharmacist, and other Practitioner, when available In the Federal Register June 16 th 2016, Center for Medicare and Medicaid Services proposed 5 new conditions for participation, one of which is Requirements for antibiotic stewardship programs to help reduce inappropriate antibiotic use and antimicrobial resistance." IDSA/SHEA guideline 2016 IDSA/SHEA recommendations: Preauthorization vs. Prospective audit of antibiotic prescriptions Preauthorization and/or prospective audit of prescribing improve antibiotic use and are a core component of any stewardship program Preauthorization: Clinicians must get approval to prescribe certain antibiotics Example: If vancomycin is prescribed, it must be approved within 24hrs Prospective audit and feedback (PAF): Engages provider after antibiotics are prescribed Example: For a patient with community-acquired pneumonia, feedback is given early in the course on appropriateness of drug, dose, route, and duration 4

5 IDSA/SHEA 2016: Education Passive education can complement an active ASP, but it is not sufficient to expect that education alone will make a significant impact on appropriate prescribing 5

6 IDSA/SHEA 2016: Local practice guidelines Standardization of treatment based on local and national practice guidelines, and local resistance patterns is an effective way of limiting inappropriate drug, dose, route, and duration decisions Example: Prospective audit and written/verbal feedback for patients with CA-UTI Example: Algorithms and order sets to assist ordering by syndrome IDSA/SHEA 2016: Utility in limiting CDI ASP s have been shown to reduce CDI through restriction of high-risk antibiotics and limiting unnecessary broad-spectrum antibiotic use IDSA/SHEA 2016: Computerized decision support If sufficient IT resources are available, computerized clinical decision support tools can be effective in guiding prescribing. This approach is labor-intensive in the design phase but limits the time associated with prospective audit. This approach has been shown to improve appropriatenss of choice and dosing, decreased resistance, and decreased costs 6

7 IDSA/SHEA 2016: Antibiotic cycling More research is needed to determine whether cycling strategies are effective IDSA/SHEA 2016: Pharmacokinetic monitoring Pharmacokinetic monitoring and adjustment has been associated with more rapid achievement of therapeutic levels, decreased cost, decreased drug toxicity, and shorter length of stay. IDSA/SHEA 2016: Transition to oral therapy Several studies have shown that programs promoting appropriate transition to po antibiotics reduce drug costs and length of stay without harming outcomes 7

8 IDSA/SHEA 2016: Beta lactam allergy assessment About 20% of hospitalized patients requiring antibiotics report beta-lactam allergy Negative allergy assessment and PCN skin-testing has been shown to allow safe prescription of betalactams under certain circumstances. IDSA/SHEA 2016: Promotion of shorter antibiotic durations Prospective audit of CAP was shown to decrease antibiotic duration by 3 days, without increase in readmission. IDSA/SHEA 2016: Stratified antibiograms Antibiograms stratified by unit (i.e. ICU vs. non- ICU) can provide useful information that may improve clinical outcomes, though evidence is sparse. 8

9 IDSA/SHEA 2016: Cascade reporting of susceptibility results Cascade reporting can guide clinicians toward preferred antibiotics and away from less efficaceous, more toxic and more expensive alternatives Example: For enterococci susceptible to ampicillin and vancomycin, do not report (suppress) susceptibility report for daptomycin, linezolid IDSA/SHEA 2016: Rapid viral diagnostics Antibiotic use in outpatient and emergency department settings is more difficult to influence than inpatient prescribing Rapid viral diagnostics can reduce inappropriate prescriptions Example: Respiratory viral battery can reduce antibiotics in upper respiratory infection IDSA/SHEA 2016: Rapid diagnostics for blood specimens Technologies such as mass spectrometry can identify bacterial species and even susceptibilities more rapidly than traditional testing, allowing earlier transition from empiric to definitive therapy 9

10 IDSA/SHEA 2016: Procalcitonin Some European studies have shown that serial PCT measurement in ICU s has decreased antibiotic use IDSA/SHEA 2016: Outcome metrics Days of therapy may be a preferred to Defined Daily Dose as an accurate measure of antibiotic duration Antimicrobial resistance patterns on a facility level may be insufficiently sensitive to reflect the quality of an ASP IDSA/SHEA 2016: Measuring cost savings Cost savings are more accurately reflected in looking beyond just drug acquisition cost, to include the costs of administration, therapeutic drug monitoring, outpatient IV therapy costs (ie home health and PICC line), and cost of toxicities avoided. 10

11 IDSA/SHEA 2016: is stewardship useful in nursing facilities? Stewardship programs have been shown to reduce antibiotic use, CDI, and cost at nursing facilities Provider, patient, and family education JCAHO requirement includes the provision of education to providers, patients, and families regarding the appropriate use of antibiotics. Conferences, special events, real-time guidance for providers Get Smart about Antibiotics Week (November 14 th -20 th, 2016) Patient/family education re: non-prescription for specific syndromes (ie URI, pharyngitis with negative strep test) Others Antimicrobial stewardship conclusions There are many tools available to provide effective AS services AS is labor-intensive and requires a significant commitment by facility leadership It takes time to grow an ASP from zero to the final product Interventions should be actively evaluated continuously Stewardship interventions must be tailored to available resources as well as patient populations (inpatient vs. outpatient, pediatric vs. adult, ICU vs. non-icu, hemeonc, hospice, nursing home, etc) All acute care hospitals are required by JCAHO to have an ASP 11

12 Thank you! Questions? 12

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