Antimicrobial Stewardship Programs The Same, but Different. Sara Nausheen, MD Kevin Kern, PharmD

Transcription

1 Antimicrobial Stewardship Programs The Same, but Different Sara Nausheen, MD Kevin Kern, PharmD

2 Antimicrobial Stewardship Programs The Same, but Different Objectives: Outline the overall function of an antimicrobial stewardship program. Discuss antimicrobial stewardship initiatives and activities that could be included in a stewardship program. Identify metrics to measure the impact of a stewardship program. Identify additional references and resources for further information and assistance in developing an antimicrobial stewardship program.

3 Antimicrobial Stewardship CDC Core Elements Leadership commitment Accountability Drug expertise Action Hospital => Implementing at least one recommended action, such as systemic evaluation of ongoing treatment need after a set period of initial treatment; e.g. antibiotic time out after 48 hours. NH => Implement at least one policy or practice to improve antibiotic use. Tracking Hospital => Monitoring antibiotic prescribing and resistance patterns NH => Monitor at least one process measure of antibiotic use and at least one outcome from antibiotic use in your facility Reporting Education

4 The Joint Commission Antimicrobial Stewardship Standard Hospitals, CAHs and Nursing Care Centers Standard MM Elements of Performance Leaders establish antimicrobial stewardship as an organizational priority. Educate staff and licensed independent practitioners involved in antimicrobial prescribing about antimicrobial resistance and antimicrobial stewardship practices Occurs upon hiring and periodically thereafter Educates patients/residents, and there families as needed, regarding the appropriate us of antimicrobial medications. Has an antimicrobial stewardship multidisciplinary team that includes the following members: ID physician, Infection preventionist(s), Pharmacist(s) and Practitioner Part-time or consultant staff and telehealth staff are acceptable members The antimicrobial stewardship program includes the CDC s core elements of stewardship. Uses organization-approved multidisciplinary protocols E.g. Antibiotic formulary restrictions, Treatment protocols for CAP, SSTIs, UTIs, etc., IV to PO conversion Collects, analyzes and reports data on its antimicrobial stewardship program Takes action on improvement opportunities identified in its antimicrobial stewardship program.

5 Centers for Medicare and Medicaid Services Proposed Requirements Promoting Antimicrobial Stewardship Section 1.C. Systems to Prevent Transmission of MDROs and Promote Antimicrobial Stewardship 1.C.9: Has written policies and procedures whose purpose is to improve antibiotic use (antibiotic stewardship) 1.C.10: Has designated a leader (e.g. physician, pharmacist, et.) responsible for program outcomes. 1.C.11: Policy and procedures requires practitioners to document in the medical record or during order entry an indication for all antibiotics, in addition to other required elements such as dose and duration. 1.C.12: The hospital has a formal procedure for all practitioners to review the appropriateness of any antibiotic prescribed after 48 hrs from the initial order (e.g. antibiotic time out) 1.C.13: Monitors antibiotic use at the unit and/or hospital level

6 Antimicrobial Stewardship What is it? Per IDSA/SHEA guideline: Coordinated interventions designed to improve and measure the appropriate use of antibiotic agents by promoting the selection of optimal drug regimen including dosing, duration of therapy, and route of administration.

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8 Antimicrobial Stewardship Altru Hospital s Policy Statement FUNCTION: The Antimicrobial Stewardship program will promote the judicious and effective use of antimicrobial agents; e.g. proper selection, dosing, route and duration of antimicrobial therapy throughout the health care system. The program will also be responsible for instituting the principles of antimicrobial stewardship to optimize clinical outcomes in infectious diseases The program will also function as a patient safety initiative by minimizing the untoward effects of antimicrobials; i.e. adverse reactions, resistance and the promotion of select pathogenic organisms such as Clostridium difficile.

9 Antimicrobial Stewardship Altru Hospital s Policy Statement ANTIMICROBIAL STEWARDSHIP ACTIVITIES: Activities of the Antimicrobial Stewardship Program will include, but are not limited to the following: Prospectively review and audit antimicrobial usage for appropriateness and provide direct feedback to prescribers. Duplicate therapy, broad-spectrum/combination regimens (antimicrobial timeout at 48hrs) Empiric and definitive therapy on all positive blood cultures, Indications for utilization of restricted antimicrobials Ensure appropriate antimicrobial dosing and monitoring; e.g. per Altru Pharmacy protocol for renal dose adjustment of antimicrobials

10 Antimicrobial Stewardship Activities/Initiatives Antibiotic indication at time of order Define durations of therapy by indication Develop dosing protocols for your institution. Dosing per pharmacy; e.g. vancmycin Renal dose adjustment Extended infusion protocols Piperacillin/tazobactam, cefepime, meropenem

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13 Antimicrobial Stewardship Altru Hospital s Policy Statement Antimicrobial Stewardship Activities: Review resistance patterns, MDRO incidence/occurrence trends and antimicrobial utilization (e.g. in days of therapy). These should be a core elements of any stewardship program.

14 Altru Hospital Antibiogram - All Floors: July 1, June 30, 2016

15 Altru Hospital Antibiogram - ICU: July 1, June 30, 2016

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18 Antibiotic Usage Data

19 Antibiotic Usage Data by Unit

20 Antimicrobial Utilization 2016 DOT/1000patient days Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Ampicillin Amp/sulb Nafcillin Pcn G Pip/tazo Cefazolin Cefepime Ceftriaxone Ceftaroline Cephalex Ertapenem Meropenem Cipro Levoflox Gent Tobra Aztreonam Clinda Metronid Bactrim Doxy Vanco IV Daptomycin Linezolid Tigecycline Monthly Total

21 Antimicrobial Stewardship Activities/Initiatives Implementing an Antibiotic Stewardship Program: Guidelines by the IDSA and the SHEA. idsociety.org Preauthorization and/or Prospective audits and feedback Considered core components Current prospective audits and feedback categories we are doing at Altru Restricted antibiotics; e.g. daptomycin Duplicate antipsudomonal/gram-neg therapy Meropenem All positive blood cultures

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23 Antimicrobial Stewardship Activities/Initiatives Implementing an Antibiotic Stewardship Program: Guidelines by the IDSA and the SHEA. idsociety.org Institution/facility specific treatment protocols/order sets E.g. community-acquired, health-care associated and hospital/ventilator associated pneumonia Review and/or develop interventions for specific ID syndromes E.g. Urinary tract infections/asymptomatic bacteriuria Target antibiotics associated with a high-risk of C difficile infections E.g. Clindamycin, 3 rd generation cephalosporins; fluoroquinolones

24 Antimicrobial Stewardship Activities/Initiatives Implementing an Antibiotic Stewardship Program: Guidelines by the IDSA and the SHEA. idsociety.org PK/PD antibiotic dosing Continuous or extended infusions Changing IV to PO therapy when appropriate Penicillin allergy assessment Significant barrier to appropriate antibiotic use Procalcitonin Shorten duration of antibiotic therapy in ICU patients Avoiding initiation of antibiotic therapy when procalcitonin is low; e.g outpatient setting

25 Antimicrobial Stewardship Activities/Initiatives Implementing an Antibiotic Stewardship Program: Guidelines by the IDSA and the SHEA. idsociety.org Microbiology initiatives Selective or cascade sensitivity reporting Rapid diagnostic testing Blood culture rapid PCR ID Respiratory pathogen PCR panel MRSA PCR screening De-escalation of vancomyin/linezolid in patients with pneumonia

26 Specialized Antimicrobial Stewardships Stewardship within stewardship EOD/urgent care antimicrobial stewardship Pediatric/NICU antimicrobial stewardship Surgery antimicrobial stewardship

27 Antimicrobial Stewardship Metrics Resistance trends Antibiograms Incidence reports; e.g. ESBLs, C diff Antibiotic usage => Days of Therapy (DOT Antibiotic expenditures # prospective audits Antibiotic time out compliance Impact of specific initiatives

28 Antimicrobial Stewardship Metrics

29 Antimicrobial Stewardship Metrics Impact of MRSA screening on vancomycin utilization for pneumonia Compared vancomycin use/cost in pneumonia patients between a 3 month period before protocol implementation and 3 months after protocol implementation 7% decrease in use by DOT; 13% decrease by total # of grams 19% decrease in the number of vancomycinlevels ordered Approximately $13,000 cost avoidance for the 3 month study period Does not include potential costs avoided from vancomycininduced AKI

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31 Antimicrobial Stewardship Metrics $54,818 in cost savings for the post BCID patient group.

32 Antimicrobial Stewardship Getting Started - Resources The Centers for Disease Control Core Elements for Hospitals and Nursing Homes American Hospital Association Antimicrobial Stewardship Toolkit The Joint Commission Joint Commission Resources; Standards Infectious Diseases Society of America Guideline for implementing Antimicrobial Stewardship Program Treatment guidelines; e.g. CAP, C diff, etc. National Quality Forum: Antibiotic Stewardship in Acute Care: A Practical Playbook MAD-ID: Antimicrobial Stewardship Training Program

33 Antimicrobial Stewardship Getting Started - Resources Minnesota Antimicrobial Stewardship Program Toolkit for Long-term Care Facilities Minnesota Dept of Health www. health.state.mn.us

34 Antimicrobial Stewardship 1969: US Surgeon General William H Stewart announced The time has come to close the book on infectious diseases. 1976: WHO sets goal to eradicate infectious diseases by the year : World Economic Forum (annual report) arguably the greatest risk to human health comes in the form of antibiotic-resistant bacteria. We live in a bacterial world where we will never be able to stay ahead of the mutation curve. A test of our resilience is how far behind the curve we allow ourselves to fall.

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