Antibiotic Stewards: Partners in Infection Control

Transcription

1 Antibiotic Stewards: Partners in Infection Control Krispin Hajkowicz Infectious Diseases Physician Antimicrobial Stewardship Lead Physician Royal Brisbane and Women's Hospital

2 The Problem

3 The problem Clostridium difficile Multi-resistant gram-negatives, MRSA, VRE, Gonococcus Adverse effects Complications of venous access and increased length of stay Cost

4 Orthopaedic Dictionary heart \härt\ noun: pump for keflin.

5 Antimicrobial Stewardship an ongoing effort by a health-care institution to optimise antimicrobial use among hospital patients in order to improve patient outcomes, ensure costeffective therapy and reduce adverse sequelae of antimicrobial use (including antimicrobial resistance) MacDougall C, Polk R. Antimicrobial stewardship programs in health care systems Clinical Microbiology Review 2005;18(4):

6 Executive sponsorship Appropriate human, financial and infrastructure resources allocated Multidisciplinary AMS team Accessible guidelines/prescriber policy Point prevalence survey or other monitoring Prescriber education System in place to ensure specialist advice for specific conditions A system for monitoring effectiveness Antimicrobial restrictions Electronic system recommended

7 Healthcare Standard 3.14 Links closely with standard 4 on medication safety Different expectations based on size of hospital (eg, Infectious Diseases Physician support may be by phone for rural hospitals

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9 Objectives Give patients with suspected infections appropriate empirical antimicrobials Optimise antimicrobials in proven infections Optimal route, dose, duration Improve the outcome of infections Avoid the inappropriate use of antimicrobials No infection Excessively broad spectrum Safer or cheaper alternatives Use prophylactic antibiotics efficiently within evidence-based guidelines and rarely after incision or >24 hours Enhance collaboration, education and research

10 Outcomes Prevent death and morbidity from infection Prevent morbidity and mortality related to the emergence of multiresistant organisms and Clostridium difficile Minimise adverse effects from antimicrobials and their administration Reduce cost and bed occupancy

11 Interventions Audit and feedback Front-end restriction and authorisation Back-end streamlining and de-escalation of antimicrobial therapy Collaborative development of guidelines Better documentation of antimicrobial orders Streamline prophylactic antibiotic use Optimal dose, route and duration Intravenous-to-oral conversion Home-based iv antibiotics utilisation Education, collaboration and communication Prospective audit and feedback Clinical champions

12 Evidence of AMS Efficacy Davey Cochrane Review 1 Reduction in Clostridium difficile infection, often substantial Reduction in colonisation by resistant gram-negatives Reduction in colonisation by VRE Reduction in colonisation by MRSA Improved outcome of infection Reduction in adverse effects from QUM literature Cost reduction 22-36% 2 In the good old days 1. Davey P. Cochrane Collaboration 2013; CD Dellit TH Clin Infect Dis 2007:44; 159.

13 Agent versus Syndrome-Based Stewardship Agent-Based Traffic light system Divert to other antimicrobials instead Syndrome-Based CAP Bacteraemia Combined approach is best

14 Starting Up an AMS Service AMS Committee Risk assessment Business Case GROAN! Potential for cost recovery Executive Support AMS Pharmacist AMS Physician AMS Summit Then do something loud!

15 AMS Committee Reports to drugs committee Infectious diseases physicians Medical microbiologists Medical administration Infection control Pharmacy Medical Education Surgery and anaesthetics Emergency medicine Information technology Research subcommittee Electronic system implementation subcommittee

16 Audit and Feedback Hospital-wide and unit-specific point prevalence surveys Forwarn the units/invite to participate Agent or syndromic approach Anticipate problems with Haematology Respiratory ICU Individual surgeons Seemingly ineffective as a single intervention in community settings

17 Point Prevalence Survey Whole of hospital, but don t do all in the same day Try to break into 2 hour blocks Use unit s own guidelines, hospital guidelines or therapeutic guidelines:antibiotic Give the benefit of the doubt to the prescriber Try to audit each bed once, problem areas twice and the Mordor unit four times Include ICU, ID ward, emergency department and try to do theatres if possible Try to audit other medications, eg PPIs or G-CSF at the same time Exclude mental health, outpatients and day treatment units Team of at least three AMS Pharmacist ID Physician Runner Plan for 2 hours for a thirty bed ward with moderate antibiotic use ID Physician for one hour

18 Point Prevalence Survey Likely outcomes ~40% of all patients on an antimicrobial ~25% - indication not documented on the medication chart or in the patient medical record ~40% inappropriate, but highly variable by unit Appropriateness particularly difficult to determine for prophylaxis Data for: Grand Rounds, Executive, Business Case, Individual Unit Meetings % inappropriate UROL PLAS GASTRO RESP NSURG % inappropriate by UNIT (n>5 only) DEM GYN MONC VAS SURG ENT Unit OBS ORTHO GERI ICU Grand Total RONC MED HAEM RENAL

19 Enhanced documentation of Antimicrobial Orders Indication for antimicrobial written on medication chart and in notes Duration or stop/review date written on medication chart

20 Unit Education Meetings Try to find the meeting that actual prescribers attend Anticipate much less hostility than you think Anticipate that the consultants have no idea what their registrars are doing and want more ID oversight Bring resistance data (and a friendly microbiologist) if at all possible Be prepared to discuss everything related to infection in that unit and to be asked to develop a guideline at the end of it

21 Front-end Restriction and Authorisation The centrepiece of any AMS Electronic and manual versions Phone advice from infectious diseases physician Antimicrobial stewardship round Law of unintended consequences Restrict meropenem everyone ends up on a fluoroquinolone instead Restrict azithromycin switch to moxifloxacin Caution in leaving infected, unwell patients without antibiotics

22 Manual Systems Easy to deploy Reasonably effective 40% reduction in meropenem use ex-icu before creep back Lots of work on the phone Law of unintended consequences

23 Electronic Stewardship Systems Guidance MS Melbourne Health easy Healthcare software/north Sydney Local Health District D.I.Y.

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25 Electronic Approvals Systems Marked increase in reach, scope and auditing Getting better all the time Expensive Have to deal with IT and accountants

26 Stewardship Team Round Daily round Patient list generated by Guidance MS Stewardship Team Pharmacist ID Consultant and/or Registrar Others,?microbiologists,?clinical champions Separate from consult service

27 Streamlining and De-escalation Specific, narrow spectrum Based on microbiology results De-escalation of empirical therapy Time-limited authorisations Stop when cultures negative at 48 hours?use of procalcitonin/crp and other biomarkers De-escalation ICU ward Duration written on medication chart Surprisingly controversial!

28 Guidelines/Clinical Pathways Very likely already to exist Only do new ones if there is a genuine need, and only unit specific ones if there is really something special about a unit Consensus is very hard a major guideline in a big hospital, eg febrile neutropenia will take at least six months and you will have to p@!# off someone Compelling, hard to argue against Have to manage Implementation and adherence Review date Owner Critical incident management

29 Intravenous to Oral Switch Selection of high oral bioavailability alternatives Eg amoxycillin+clavulanate for pip-tazo Oral clindamycin for lincomycin Oral metronidazole, ciprofloxacin, voriconazole, fluconazole, azithromycin De-escalation guidelines for pneumonia, pyelonephritis, FN, etc Automatic switch based on pre-defined criteria 1 Length of stay, cost, iv access complications Patient empowerment BUT: Oral antibiotics led to greater enhancement of antibiotic resistant gene pools in the microbiota of mouse faeces compared with the same antibiotic IV 2 1. Przybylski. Pharmacotherapy 1997; 17(2): Zhang L. Antimicrob Ag Chemo 2013; 20 May epublished prior to publication

30 Prophylaxis Surgical prophylaxis can account for up to 50% of all antimicrobial use Evidence-based guidelines Limited evidence for post-incision prophylaxis with a few exceptions Even less evidence for prophylaxis >24hr Anaesthetists the key craft group?abs stopped by pharmacist/ams team

31 Clinical Champions

32 Dose Optimisation Vancomycin Aminoglycosides Benzylpenicillin q4h Piperacillin+tazobactam q6h

33 Ineffectual Antimicrobial Stewardship Interventions Antimicrobial cycling Combination therapy

34 Other AMS Activities Competitive tenders for very high cost drugs Proton pump inhibitors G-CSF, erythropoietin Blood products Any new, dangerous or expensive drug or therapy

35 Combine AMS and Hospital-in-the-Home Highly synergistic, critical to do stewardship for cellulitis/hith, cost-savings ICU, haematology, onology burns unit ward rounds NEAT targets Quality Use of Medicines (QUM) strategy Unit Quality and Safety Meetings

36 Thank you! Anna Klusak, Royal Brisbane Hospital AMS Pharmacist David Paterson and Tony Allworth, ID Physicians RBWH Amanda Dines, Executive Director Cancer Care Services Dellit TH, Paterson DL, et al. IDSA/SHEA Guidelines for developing an institutional program to enhance antimicrobial stewardship. Clin Infect Dis 2007; 44: