Jump Starting Antimicrobial Stewardship

Transcription

1 Jump Starting Antimicrobial Stewardship Amanda C. Hansen, PharmD Pharmacy Operations Manager Carilion Roanoke Memorial Hospital Roanoke, Virginia March 16, 2011

2 Objectives Discuss guidelines for developing institutional programs to enhance antimicrobial stewardship Review successful strategies for obtaining buy-in and compliance with antimicrobial restrictions Describe the infection control / stewardship relationship

3 Goals of Antimicrobial Stewardship Optimize antimicrobials Selection Dose Route Duration of therapy Limit inappropriate antimicrobial use Maximize clinical outcomes Prevent infection Limit unintended consequences Dellit et al. Clin Infect Dis 2007;44:

4 Antimicrobial Use and Resistance Changes in use reflect changes in resistance Nosocomial organism resistance > Community acquired organism resistance Patients with HAI more likely to have prior antimicrobial use Floors/units with highest rates of resistance have highest rates of use duration of antimicrobial exposure increases likelihood of resistant organism colonization Dellit et al. Clin Infect Dis 2007;44:

5 Infection Control Professional Hospital Administration Information Systems Medical Staff Leadership Clinical Microbiology Director, Antimicrobial Management Program Hospital Epidemiologist Infectious Diseases Faculty Infectious Diseases Clinical Pharmacist Chairman, P&T Committee Outcomes Management

6 Antimicrobial Stewardship Strategies

7 Prospective Audit With Intervention and Feedback Rules-based computer systems to identify microbiologic and antimicrobial data Target organisms or antimicrobials Timely communication of recommendations Identify common themes Staff or services that heavily use antimicrobials Drew et al. Pharmacotherapy 2008;29:

8 Prospective Audit With Intervention and Feedback Large academic medical center Targeted two antimicrobials 37% reduction in days of unnecessary therapy Medium sized community hospital 22% decrease in use of parenteral broad-spectrum antimicrobial use Decreased C. difficile rates Decreased HAI associated with MDR Enterobacteriaceae Dellit et al. Clin Infect Dis 2007;44: Carling et al. Infect Control Hosp Epidemiol 2003;24: Solomon et al. Arch Intern Med 2001;161:

9 Formulary Restriction and Approval Requirements Most effective method of controlling antimicrobial use Effective during nosocomial epidemics Data for long term effect on resistance are mixed squeezing the balloon Significant cost reduction Dellit et al. Clin Infect Dis 2007;44:

10 Formulary Restriction and Approval Requirements Improving Buy-In Policy approved by medical executive committee Grant time-restricted approvals (24-72 hours) Regularly review use of restricted agents Use CPOE to notify prescribers at the time of order Dedicated pagers and approval team members CPOE computerized prescriber order entry Drew et al. Pharmacotherapy 2009;29:

11 Supplemental Strategies Education Conference presentations Housestaff teaching sessions Technology-based alerts Infectious Diseases rotation experiences Guidelines and Clinical Pathways Multidisciplinary development of evidence based practice guidelines; enroll opinion leaders ( Champions ) Incorporate local susceptibility patterns and formulary IV to PO Protocols Discharge planning Dellit et al. Clin Infect Dis 2007;44: Drew et al. Pharmacotherapy 2009;29:

12 Clinical Decision Support Technology Key characteristics Access intelligently filtered information Prompt when appropriate Offer guided choices to enhance care Provide feedback for outcomes analysis Example Sentri7 Pestotnik SL. Pharmacotherapy 2005;25:

13 Antimicrobial Cycling Minimize antimicrobial selection pressures Difficult to implement 10-50% of patients receive off-cycle agents due to allergies, adverse effects, or conflicts with national guidelines Resistance is reduced short term but rapidly returns once the antimicrobial of concern is reintroduced Data supporting cycling practices limited, plagued by confounders Dellit et al. Clin Infect Dis 2007;44:

14 ICU Cycling Data Spanish university hospital 2 Med ICUs 346 patients Cycled anti-pseudomonas regimens (1/month) Planned antibiotics used 45% Increased resistance to cefepime Trend toward increased resistance to ceftazidime, meropenem, and imipenem No difference in rate acquisition of MDR Gramnegative Martinez et al. Crit Care Med 2006;34:

15 ICU Cycling Data UVA medical ICU, prospective cohort 301 patients Cycled anti-pseudomonas regimens (1/quarter) P. aeruginosa outbreak at cycle 3 and 4 No difference in mortality Increased number of patients acquired an infection followed by in-hospital death Multiple limitations, no definitive association between cycling and outbreak Hedrick et al. Surgical Infections 2008;9:

16 Combination Therapy Rationale improved clinical outcomes, prevent resistance Role in treatment of MDR organisms or patients with severe sepsis Data are limited, combination therapy often redundant and unnecessary Dellit et al. Clin Infect Dis 2007;44:

17 De-escalation Continuation of excessively broadspectrum therapy contributes to resistance De-escalation may result from Microbiologic data (or negative cultures) Clinical data Goals: decrease antimicrobial exposure, decrease cost Dellit et al. Clin Infect Dis 2007;44:

18 Dose Optimization Patient characteristics Age Renal function Weight Causative organism Site of infection (meningitis, osteomyelitis) Drug characteristics Dellit et al. Clin Infect Dis 2007;44:

19 Microbiology Lab Prioritization of tested antimicrobials Selective reporting of susceptibility profiles Molecular diagnostics Resistance surveillance Local antibiograms Routine assessment of MIC data Partner with Infection Control, Hospital Epidemiologist Dellit et al. Clin Infect Dis 2007;44:

20 Infection Control / ASP Collaboration IC collects highly detailed nosocomial infection data May assist with the ASP team s evaluation of outcome strategies or target efforts ASP can assist to control or monitor antimicrobial use during an outbreak Opportunities to reduce resistance and improve patient outcomes MacDougall et al. Clinical Microbiology Reviews 2005;18:

21 Jump Starting Antimicrobial Stewardship Amanda C. Hansen, PharmD Pharmacy Operations Manager Carilion Roanoke Memorial Hospital Roanoke, Virginia March 16, 2011