8/17/2016 ABOUT US REDUCTION OF CLOSTRIDIUM DIFFICILE THROUGH THE USE OF AN ANTIMICROBIAL STEWARDSHIP PROGRAM

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1 Mary Moore, MS CIC MT (ASCP) Infection Prevention Coordinator Great River Medical Center, West Burlington REDUCTION OF CLOSTRIDIUM DIFFICILE THROUGH THE USE OF AN ANTIMICROBIAL STEWARDSHIP PROGRAM ABOUT US Great River Health Systems is located in the southeastern part of the state, serving Iowa, Illinois and Missouri. It is comprised of a 240-bed regional hospital, a new 165-bed long term care center, a 5-bed hospice house, home health care and hospice services and numerous outpatient clinics. Our Mission: Great River Health Systems is dedicated to improving the region s health by providing high-quality care, world-class customer service, and uncompromising value to our patients and their families. Our Vision: Great People, Great Care, Great River 1

2 DEFINING THE PROBLEM Antibiotic Resistance In India, 58,000 babies died in one year from super-resistant bacterial infections, which are usually passed on from their mothers In the EU, antibiotic resistance causes 25,000 deaths/year and 3.2M hospital days In Thailand, antibiotic resistance causes 38,000 deaths/year In the US, antibiotic resistance causes 23,000 deaths/year and more than 2M illnesses CAUSES OF ANTIBIOTIC RESISTANCE POOR ANTIBIOTIC PRESCRIBING PATTERNS Although antibiotics save lives, they put patients at risk for Clostridium difficile (C diff) infections (250,000 infections and 14,000 deaths/year in hospitalized patients) Decreasing use of antibiotics could lead to 26% fever cases of C. diff Patients getting powerful antibiotics, that treat a broad range of infections, are up to 3 times more likely to get another infection from an even more resistant bacteria - CDC 2

3 BACTERIAL VS. VIRAL INFECTIONS IMPROVING ANTIBIOTIC PRESCRIBING EVERY TIME ANTIBIOTICS ARE PRESCRIBED Order cultures before antibiotics are given and start drugs promptly Make sure indication, dose, expected duration are specified Reassess within 48 hours and adjust prescription if necessary or stop antibiotics 3

4 SPECIFIC RECOMMENDATIONS FOR COMMON PRESCRIBING SITUATIONS Urinary Tract Infections True infection, not colonization Recommended length, post-discharge treatment accounts for antibiotics given in hospital as well Pneumonia Same as above MRSA infections Need to grow from relevant culture Don t use vancomycin to treat methicillin sensitive Staph aureus (MSSA) ANTIMICROBIAL STEWARDSHIP PROGRAM Leadership commitment Dedicate necessary staff, financial, IT resources Accountability Single leader responsible of program outcome Drug expertise Single ID trained pharmacist Act At least one prescribing improvement action Track Report Educate Work with other health care facilities to prevent infections, transmission and resistance - CDC STEWARDSHIP TEAM AT GRHS Infectious Disease Physician Pathologist Family Practice Physician ARNP LTC Hospitalist Director of Pharmacy Clinical Pharmacy Coordinator Clinical Informatics Pharmacist LTC Pharmacy Coordinator Microbiology Technical Specialist Infection Preventionist 4

5 COMMUNITY HEALTH PERSPECTIVE Representation Inpatient Long term care Outpatient clinics SITUATION AT GRHS In 2012, a steady increase in the rate of hospital-acquired C diff was identified Surveillance efforts correlated the occurrence of these infections to antimicrobial use, especially the use of the fluoroquinolones for urinary tract infections RISK FACTORS FOR C DIFF ASSOCIATED DISEASE (CDAD) Antimicrobial use, especially clindamycin, fluoroquinolones and cephalosporins Advanced age Recent and repeated hospitalizations Use of proton pump inhibitors (PPIs) Co-morbid conditions, especially chronic renal failure 5

6 BACKGROUND Long hospital stays 12.4% of patients with C diff infections stayed in the ICU for a mean length of stay of 12 days* Need for multiple consultations Increased costs Average total cost $35,621* *Palli S et al, Cost drivers associated with Clostridium difficile infection in a hospital setting, ASHP 2012;Abstract ASSESSMENT Johnston BC, Ma SS, Goldenberg JZ, et al. Probiotics for the Prevention of Clostridium difficile-associated diarrhea: A Systematic Review and Meta-Analysis. Annals of Internal Medicine, 13 November Guide to the Elimination of Clostridium difficile in Healthcare Settings, APIC, Pakyz AL, et al. The utility of hospital antibiograms as tools for guiding empiric therapy and tracking resistance: Insights from the Society of Infectious Diseases Pharmacists, Pharmacotherapy, 2007 Sep 27(9): ASSESSMENT Raineri Enrico, Pan Angelo, Mondello Placido et al. Role of the Infectious Diseases Specialist Consultant on the Appropriateness of Antimicrobial Therapy Prescription in an Intensive Care Unit, The American Journal of Infection Control, May Yahya Shehabi and Ian Seppelt, Is procalcitonin useful for guiding antibiotic decision making, in critically ill patients, Critical Care, 2008; 12(3):211. 6

7 RECOMMENDATIONS/ACTION PLAN Antibiogram Probiotics Procalcitonin Infectious Diseases Physician C diff Bundle Outcome Measures Culture Change USE OF THE ANTIBIOGRAM Definition - a collection of data, usually in the form of a table, summarizing the percent of individual bacterial pathogens susceptible to different antimicrobial agents An antibiogram is generated after bacteria are isolated (as from a patient's tissues or body fluids) and subjected to laboratory testing. Hospitals offer more directed help to their physicians by creating antibiograms, or tables, that chart the resistance patterns within a specific facility Our 2012 antibiogram showed a 77% susceptibility of E coli to levofloxacin (a fluoroquinolone) Demonstrates a 23% treatment failure Fluoroquinolones associated with an increase in the incidence of C diff Physician education Table tents at medical staff meeting EXAMPLE OF ANTIBIOGRAM 7

8 EXAMPLE OF ANTIBIOGRAM PROBIOTICS Probiotics were added to the formulary based on the Johnston study 3,000 patients Moderate quality evidence supports a large protective effect of probiotics in the prevention of C diff Given the low cost of probiotics and the moderate quality evidence suggesting the absence of important adverse effects, there seems little reason not to encourage use of probiotics in patients receiving antibiotics who are at risk for C diff. ADVERSE EFFECTS OF PROBIOTICS Consider eliminating the following high risk groups when using probiotics Patients with central venous catheters Yeast detected on hands of HCW and was isolated on the catheter hub of one of the patients Munoz, et.al. Saccharomyces cerevisiae Fungemia: An Emerging Infectious Disease, Clinical Infectious Diseases 2005:40: Patients in the ICU Immunosuppressed patients 8

9 PROCALCITONIN Biomarker that is used to diagnose and monitor severe bacterial infections and sepsis Detects bacterial infections over viral infections Drives clinical decision making Shehabi and Seppelt- This simple strategy can result in a reduction of up to 30% in the cost of antibiotics. INTERPRETATION OF PROCALCITONIN Most useful in determining bacterial sepsis Test results μg/l=normal μg/l=possible sepsis 2-10 μg/l=likely sepsis >10μg/L=Severe sepsis or septic shock INFECTIOUS DISEASES PHYSICIAN Administrative Support Raineri, Pan, Mondello, et al- introduction of an ID specialist improves the appropriateness of antimicrobial therapy in the ICU Arrival in June 2013 Interventions began in June

10 C DIFF BUNDLE 10% bleach solution Contact precautions Entire length of stay Spores are shed for up to 6 weeks after treatment Signage Brown signage CNA pericare education Community Health Education C diff pamphlet for patients Nurse-driven protocol Automatic order for C diff test if patient notes at least 3 episodes of diarrhea within 24 hours of admission Began October 2015 CULTURE CHANGE Education Return demonstrations, fliers, newsletters, medical staff and staff meetings, Q & A s and huddles Staff Involvement Piloting of C diff pamphlet, infection prevention committee involvement Communication Information sent to leaders to be communicated to staff during meetings, huddles, etc. Administrative Support Consistent with mission, vision and values OUTCOME MEASURES 10

11 OUTCOME MEASURES OUTCOME MEASURES ADDITIONAL INTERVENTIONS-REDUCING USE OF VANCOMYCIN Penicillin Binding Protein 2 Test(PbP2) Detects protein coded by meca gene in methicillin resistant staph aureus (MRSA) isolates Latex test performed by microbiologist Test has 100% sensitivity and 99% specificity Results are complete one day prior to susceptibility testing Reduces vancomycin use by one day for methicillin susceptible staph aureus (MSSA) isolates Requires physician education 11

12 ADDITIONAL INTERVENTIONS-HOSPITAL ACQUIRED PNEUMONIA PROTOCOL NEXT STEPS 48 hour reminders for antibiotics (whether to continue or stop depending on cultures), automatic vs. pharmacy calls Stop date on antibiotics Restriction of antibiotics More sophisticated testing in microbiology CRE genetic testing for screening and culture Protocols for most common infections Skin and soft tissue infections Pneumonias (VAP) QUESTIONS? 12

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