Sustaining an Antimicrobial Stewardship

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1 Sustaining an Antimicrobial Stewardship Much needless expense, untoward effect, harm and disappointment can be prevented by better judgment in the use of antimicrobials Whitney A. Jones, PharmD Antimicrobial Stewardship Coordinator Infectious Diseases Specialist MCG Health, Inc. Objectives Describe ways in which to employ local microbiologic data Discuss the use of pharmacodynamic principles to optimize clinical outcomes Identify supplemental improvement strategies for antimicrobial stewardship Discuss modes of communication of stewardship processes and outcomes Antimicrobial Selection Imparts utmost importance on antimicrobial stewardship programs It s notjust about streamlininganymore anymore Multifaceted approach Selection of appropriate antimicrobial Dose optimization Curative duration of administration Minimization of toxicity Minimization of conditions for selection of resistant strains Boucher HW, et al. Clin Infect Dis 2009; 48: Fishman N. Am J Med 2006;119:S Ibrahim EH, et al. Chest 2000;118: Clinical Microbiology Local Trends in Antimicrobial Susceptibility Critical role Timely identification and susceptibility testing Resistance surveillance Local antibiograms Pathogen specific susceptibility data Location specific susceptibility data Inpatient vs. outpatient ICU vs. ward Adaptation of national guidelines Pip tazo = Piperacillin tazobactam Goff DA. Curr Opin Infect Dis 2011;24:S

2 Clinical Microbiology Critical role Timely identification and susceptibility testing Resistance surveillance Local antibiograms Pathogen specific susceptibility data Location specific susceptibility data Inpatient vs. outpatient ICU vs. ward Adaptation of national guidelines Use of Local Microbiologic Data for Treatment of HAP Additional Antibiotic Drugs None Ciprofloxacin Gentamicin Amikacin Piperacillin 80% 82% 81% 96% tazobactam Cefepime 81% 83% 82% 96% Meropenem 82% 83% 83% 96% *Data are presented as percentage susceptible to at least one antibiotic. HAP = Hospital acquired pneumonia Beardsley JR, et al. Chest 2006;130: Treatment of Complicated Intra abdominal Infections (ciais) Don t Miss a Strep. Choosing susceptibility panels for your automated system Considerations Formulary Breakpoint, MIC or MIC/Combo Antibiogram ESBL confirmation test Inducible clindamycin screen Amp sulbactam = Ampicillin sulbactam Goff DA. Curr Opin Infect Dis 2011;24:S Pharmacokinetic/Pharmacodynamic Indices AUC: Area under the concentration time curve C max : Maximum plasma concentration Nicolau DP. Crit Care 2008; 12: S2. 2

3 β lactam Optimization Strategies Extended Infusion of Meropenem 1. Use of antibiotics with long half life 2. Increasing the dose 3. Increasing the dosing frequency 4. Increasing the infusion duration Dandekar PK, et al. Pharmacotherapy 2003;23: Extended Infusions of Doripenem Review of Clinical Benefits 1 hour infusion 4 hour infusion Meta analysis Continuous or extended infusions of β lactams Outcome Odds Ratio P value (95% confidence interval) Clinical cure 1.04 ( ) 0.83 Mortality 1.00 ( ) 1.00 Conclusions Use of continuous infusions leads to same results as higher dose antibiotic boluses Van Wart SA, et al. Diagn Microbiol Infect Dis 2009;63: Roberts JA, et al. Crit Care Med 2009;37: patients Extended infusions 102 patients Intermittent infusions 92 patients Clinically evaluable patients with serious nosocomial pneumonia, including VAP APACHE score day mortality 12.2% extended infusions vs. 31.6% intermittent infusions P = 0.04 Lodise TP, et al. Clin Infect Dis 2007;44: Chastre J, et al. Clin Infect Dis 2009;49:S

4 Pitfalls of Extended Infusions Implementation of Extended Infusions Drug compatibility Infusion pump characteristics Drug libraries Programmable vs. non programmable Lock outs Infusion volume Infusion line dead space Interruptions Identify barriers Systematic Logistics Infusion pump software Personnel Extensive education CPOE utilization Claus B, et al. Antimicrob Agents Chemother 2010;54:4950. Supplemental Strategies Information technologies CPOE Computer assisted decision support Rapid molecular diagnostic testing Antimicrobial stewardship care bundles Dellit TH, et al. Clin Infect Dis 2007;44: To Err is Human Computer assisted Management Program for Antiinfectives at LDS Computer Assisted Support Reduction of: Bug drug mismatches Overall antibiotic use Excess antimicrobial dosages Excessive dose days Allergy drug mismatches Drug related side effects Antimicrobial costs Total hospital costs Length of hospital stay CPOE Improved compliance with treatment guidelines Reduction of: Antimicrobial prescribing errors Antimicrobial costs Length of hospital stay Improved antimicrobial use Bates DW, et al. J Am Med Inform Assoc 1999;6: Rothschild J. J Crit Care 2004:19: Evans, RS, et al. N Engl J Med 1998;338:

5 ADVISE Program Proprietary Informatics P = 0.01 Diverse functions Hospital epidemiology Antimicrobial stewardship Programs available TheraDoc SafetySurveillor BD Protect Quality Compass Health Evaluation through Logical Processing (HELP) Thursky KA, et al. Int J Qual Health Care 2006;18: Computer Assisted Stewardship Rapid Molecular Testing Institution specific Implementation is challenging Technology Identification and participation of users Functionality Time Installation Validation Cost Multiplex detection recently made available Clinical outcome improvement Decreasing time to identification Provision of therapy Earlier More effective Evaluation of clinical outcomes and economic impact Rapid PCR S. aureus Blood Culture Test Rapid PCR S. aureus Blood Culture Test Bauer KB, et al. Clin Infect Dis 2010;51: Bauer KB, et al. Clin Infect Dis 2010;51:

6 Economic Impact of MRSA PCR Rapid Viral Testing Bauer KB, et al. Clin Infect Dis 2010;51: $21,387 Wake Forest University Baptist Medical Center Implementation of viral multiplex PCR 2009/2010influenza season with H1N1 Immunocompromised patients with pneumonia 10 15% viral Respiratory syncytial virus (RSV) Human metapneumovirus Rapid de escalation of antibiotic therapy if possible Ohl CA, et al. J Hosp Med 2011;6:S4 15. Antimicrobial Stewardship Care Bundles Implementation of Stewardship Care Bundles Current care bundles include antibiotics 100K lives campaign The missing care bundles Antibiotics for treatment in acute settings Antibiotics as surgical prophylaxis Incorporation into antimicrobial stewardship programs Quality indicators Documentation of treatment rationale Collection of appropriate p cultures Appropriate empiric antimicrobial selection Appropriate deescalation Cooke FJ, et al. Int J Antimicrob Agents 2007;30:25 9. Toth NR, et al. Am J Health Syst Pharm 2010;67: Communication Education, education, education Reports Community stewardship 6

7 Sustaining an Antimicrobial Stewardship Much needless expense, untoward effect, harm and disappointment can be prevented by better judgment in the use of antimicrobials Whitney A. Jones, PharmD Antimicrobial Stewardship Coordinator Infectious Diseases Specialist MCG Health, Inc. 7