Antimicrobial Stewardship. We cannot afford to go back

Antimicrobial Stewardship We cannot afford to go back

Objectives What is antimicrobial stewardship? Why the concern over antibiotic resistance? Discuss the role and use of antibacterial medical devices decreasing the use of antibiotics.

Perspective 1994 1989 1974 1959 1945 First Smartphone. Time.com http://time.com/3137005/first-smartphone-ibm-simon/ Accessed 4/24/17 History of the Web. World Wide Web Foundation. http://webfoundation.org/about/vision/history-of-the-web/?gclid=cn3epn2r5nmcfq9ldqodkjyfuw Accessed 4/24/17 Invention of the PC. History.Com http://www.history.com/topics/inventions/invention-of-the-pc Accessed 4/24/17 History of the seatbelt. Center for Auto Safety. http://www.autosafety.org/history-seat-belt-development/ Accessed 4/24//17 Discovery and Development of Penicillin. American Chemical Society. https://www.acs.org/content/acs/en/education/whatischemistry/landmarks/flemingpenicillin.html Accessed 4/24/17

Human Impact 1900 2000 Leading causes of U.S. deaths Pneumonia Tuberculosis Diarrhea and Enteritis Heart Disease Stroke Liver Disease Injuries Cancer Senility Diptheria 0% 5% 10% Disease of the heart Malignant neoplasms Cerebrovascular diseases Chronic lower resiratory diseases Accidents Diabetes mellitus Influenza and pneumonia Alzheimer's disease Nephritis Septicemia 0% 10% 20% 30% Life Expectancy 46.3 Years 48.3 Years 74.1 Years 79.5 Years 30.4% of all deaths were children under 5 1.4% of all deaths were children under 4 Achievements in Public Health, 1900-1999: Control of Infectious Diseases. The Centers for Disease Control and Prevention. https://www.cdc.gov/mmwr/preview/mmwrhtml/mm4829a1.htm Accessed 4/27/17 Life expectancy at birth, at 65 years of age, and at 75 years of age, by race and sex: United States, selected years 1900 2007. The Centers for Disease Control and Prevention. https://www.cdc.gov/nchs/data/hus/2010/022.pdf Accessed 4/27/17 Deaths: Preliminary Data from 2000. The Center for Disease Control and Prevention. https://www.cdc.gov/nchs/data/nvsr/nvsr49/nvsr49_12.pdf Accessed 4/27/17

What is it? Antimicrobial stewardship refers to coordinated interventions designed to improve and measure the appropriate use of antimicrobials by promoting the selection of the optimal antimicrobial drug regimen, dose, duration of therapy, and route of administration to reduce or avoid their use. Promoting Antimicrobial Stewardship in Human Medicine. Infectious Disease Society of America. http://www.idsociety.org/stewardship_policy/ Accessed 4/24/17

Why the concern? Antimicrobial resistance refers to microbes ability to change and become less susceptible to drugs. The development of antimicrobial drugs (antibacterials [antibiotics], antivirals, antifungals and antiparasitics) to treat otherwise lifethreatening infections has been one of the most notable medical achievements in human history. The growing problem of resistance has undermined antimicrobials effectiveness resulting in the loss of countless lives and placing public health and national security at serious risk. Antimicrobial Resistance. Infectious Disease Society of America. http://www.idsociety.org/topic_antimicrobial_resistance/ Accessed 4/24/17

Some microorganisms of concern Enterococci cause a range of illnesses, mostly among patients receiving healthcare, but include bloodstream infections, surgical site infections, and urinary tract infections. Antibiotic Resistance Threats in the United States, 2013 CDC page 67

Some microorganisms of concern Methicillin-resistant Staphylococcus aureus (MRSA) causes a range of illnesses, from skin and wound infections to pneumonia and bloodstream infections that can cause sepsis and death. Staphylococcus bacteria, including MRSA, are one of the most common causes of healthcareassociated infections. Antibiotic Resistance Threats in the United States, 2013 CDC page 77

Some microorganisms of concern Streptococcus pneumoniae (S. pneumoniae, or pneumococcus) is the leading cause of bacterial pneumonia and meningitis in the United States. It also is a major cause of bloodstream infections and ear and sinus infections. Antibiotic Resistance Threats in the United States, 2013 CDC page 79

Some microorganisms of concern Clostridium difficile (C. difficile) causes life-threatening diarrhea. These infections mostly occur in people who have had both recent medical care and antibiotics. Often, C. difficile infections occur in hospitalized or recently hospitalized patients. Antibiotic Resistance Threats in the United States, 2013 CDC page 51

Antibiotic introduction and resistance development 1950 Tetracycline 1960 Methicillin Antibiotic Introduced 1953 Erythromycin 1972 Vancomycin 1996 Levofloxacin Antibiotic Resistance Identified 1950 1960 1970 1980 1990 2000 - Today 1962 Methicillin 1988 Vancomycin 1996 Levofloxacin 1959 Tetracycline 1968 Erythromycin Antibiotic Resistance Threats in the United States, 2013 CDC page 28

Antibiotic introduction and resistance development An even bigger concern The number of new antibiotics developed and approved has steadily decreased in the past 3 decades, leaving fewer options to treat resistant bacteria NDA Number of Antibacterial New Drug Application (NDA) Approvals vs. Year Intervals* 1980-1984 1985-1989 1990-1994 1995-1999 2000-2004 2005-2009 2010-2012 *Intervals from 1980-2009 are 5-yr intervals; 2010-1012 is a 3-yr interval. Drugs are limited to systemic agents. Data courtesy of FDA s Center for Drug Evaluation and Research (CDER) Antibiotic Resistance Threats in the United States, 2013 CDC page 44

Voluntary Antibiotic Stewardship Programs in the US

Mandatory Antibiotic Stewardship Initiatives The Joint Commission recently announced a new Medication Management (MM) standard for hospitals, critical access hospitals, and nursing care centers. Standard MM.09.01.01 addresses antimicrobial stewardship and became effective January 1, 2017. September 29, 2016 Center of Medicaid and Medicare Service (CMS) finalized improvements in care, safety, and consumer protections for long-term care facility residents. Updating the long-term care facility s infection prevention and control program, including requiring an infection prevention and control officer and an antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use. CMS is in the process of developing a Condition(s) of Participation (CoP) on antimicrobial stewardship for hospitals. New Antimicrobial Stewardship Standard. Joint Commission. https://www.jointcommission.org/assets/1/6/new_antimicrobial_stewardship_standard.pdf Accessed 4/24/17 CMS finalizes improvements in care, safety, and consumer protections for long-term care facility residents. Center for Medicare and Medicaid Services. https://www.cms.gov/newsroom/mediareleasedatabase/press-releases/2016-press-releases-items/2016-09-28.html Accessed 4/24/17

So what can we do?

https://www.cdc.gov/vitalsigns/protect-patients/

Breaking the Chain of Infection Microorganism (bacteria, virus, fungi) Person susceptible to the microorganism Susceptible Host Infectious Agent Reservoirs Host which allows the microorganism to live, grow and multiply Path for microorganism to enter new host Portal of Entry Means of Transmission Portal of Exit Path for microorganism to escape from host (ex. Blood, respiratory tract, skin, etc.) Vehicle to carry to other hosts

Interesting study 47% relative reduction in the CAUTI rate observed with silver-alloy hydrogel catheter compared to standard catheter when both the old and the most recent CDC CAUTI definitions were used Antimicrobial days for CAUTIs decreased from 1165 (standard catheter period) to 406 (silver-alloy hydrogen period) Those of you who participate in the National Healthcare Safety Network s voluntary Antimicrobial Use and Resistance module and track antimicrobial days may find data like this extremely relevant. Lederer J, Jarvis W, Thomas L, Ritter, J. Multicenter cohort study to assess the impact of a silver-alloy and hydrogel-coated urinary catheter on symptomatic catheter-associated urinary tract infections. Journal of Wound Ostomy Continence Nursing. 2014 Sep-Oct;41(5):473-80

Most Bloodstream Infections and Surgical Site Infections are caused by bacteria from patients own skin HAIs Major Site of Infections Estimated No. Pneumonia 157,500 Gastrointestinal illness 123,100 Urinary tract infections 93,300 Primary bloodstream infections 71,900 Surgical site infections from any inpatient surgery 157,500 Other type of infections 118,500 Estimated total number of infections in hospitals 721,800 Reducing Surgical Site Infections: A Review. US National Library of Medicine. https://www.ncbi.nlm.nih.gov/pmc/articles/pmc2812878/ Accessed 4/24/17 Catheter-related bloodstream infections. US National Library of Medicine. https://www.ncbi.nlm.nih.gov/pmc/articles/pmc4093967/ Accessed 4/24/17 HAIs at a Glance. Centers for Disease Control and Prevention. https://www.cdc.gov/hai/surveillance/index.html Accessed 4/27/17

Skin Colonization Infectious Agent Reservoir Portal Exit Pre-Prep Bacteria colonies exist not only on the surface, but below the surface as well, particularly within the hair follicles and sebaceous glands Post-Prep (immediately following antiseptic application) Prepping the skin reduces colony counts of bacteria from the surface only it never completely sterilize the skin

Skin Colonization Means of Transmission: Central Venous Catheter Means of Transmission: Surgical Incision Susceptible host Portal of entry Susceptible host Portal of entry

Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017 Recommendation Administer preoperative antimicrobial agents only when indicated based on published clinical practice guidelines and timed such that a bactericidal concentration of the agents is established in the serum and tissues when the incision is made. Administer the appropriate parenteral prophylactic antimicrobial agents before skin incision in all cesarean section procedures. In clean and clean-contaminated procedures, do not administer additional prophylactic antimicrobial agent doses after the surgical incision is closed in the operating room, even in the presence of a drain. Do not apply antimicrobial agents (i.e., ointments, solutions, or powders) to the surgical incision for the prevention of SSI. Application of autologous platelet-rich plasma is not necessary for the prevention of SSI. Implement perioperative glycemic control and use blood glucose target levels less than 200 mg/dl in patients with and without diabetes Maintain perioperative normothermia. For patients with normal pulmonary function undergoing general anesthesia with endotracheal intubation, administer increased FIO2 during surgery and after extubation in the immediate postoperative period. Advise patients to shower or bathe (full body) with soap (antimicrobial or nonantimicrobial) or an antiseptic agent on at least the night before the operative day Perform intraoperative skin preparation with an alcohol-based antiseptic agent unless contraindicated. Application of a microbial sealant immediately after intraoperative skin preparation is not necessary for the prevention of SSI. The use of plastic adhesive drapes with or without antimicrobial properties is not necessary for the prevention of SSI. Consider intraoperative irrigation of deep or subcutaneous tissues with aqueous iodophor solution for the prevention of SSI. Do not withhold transfusion of necessary blood products from surgical patients as a means to prevent SSI. In prosthetic joint arthroplasty, recommendation 1E applies: in clean and clean-contaminated procedures, do not administer additional antimicrobial prophylaxis doses after the surgical incision is closed in the operating room, even in the presence of a drain. Classification Category IB Category IA Category IA Category IB Category II Category IA Category IA Category IA Category IB Category IA Category II Category II Category II Category IB Category IA Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017. JAMA Network. http://jamanetwork.com/journals/jamasurgery/fullarticle/2623725 Accessed 4/27/17

Triclosan Coated Sutures Recommendations Consider the use of triclosan-coated sutures for the prevention of SSI. CDC Guideline for the Prevention of Surgical Site Infections 2017* * The CDC, WHO, ACS & SIS guidelines on reducing the risk of surgical site infections are general to triclosan-coated sutures and are not specific to any one brand. Berríos-Torres SI, Umscheid CA, Bratzler DW, et al. Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017. JAMA Surg. http://jamanetwork.com/journals/jamasurgery/fullarticle/2623725 Accessed 4/25/17

Triclosan Coated Sutures Recommendations Triclosan antibacterial suture use is recommended for wound closure in clean and clean-contaminated abdominal cases when available American College of Surgeons & Surgical Infection Society (ACS & SIS) Surgical Site Infection Guidelines* * The CDC, WHO, ACS & SIS guidelines on reducing the risk of surgical site infections are general to triclosan-coated sutures and are not specific to any one brand. Journal of the American College of Surgeons. DOI: http://dx.doi.org/10.1016/j.jamcollsurg.2016.10.029. Accessed 4/24/17

Triclosan Coated Sutures Recommendations The panel suggests the use of triclosan-coated sutures for the purpose of reducing the risk of SSI, independent of the type of surgery World Health Organization (WHO) Global Guidelines for the Prevention of Surgical Site Infection* * The CDC, WHO, ACS & SIS guidelines on reducing the risk of surgical site infections are general to triclosan-coated sutures and are not specific to any one brand. Infection prevention and control. World Health Organization website. http://www.who.int/infection-prevention/publications/ssi-guidelines/en/ Accessed 4/24/17

Prospectively planned meta-analyses of randomized control trials were performed on the use of suture containing triclosan to lower SSI rates

Significance of the recommendation Three new evidence-based SSI prevention guidelines were published in peer-reviewed medical literature. The ground-breaking news across all of these guidelines is that for the first time, the choice of a wound-closure device is being recognized as an evidence-based component within a bundle of interventions aimed at addressing risk factors for SSI.

Reducing Colonization The petri dish image is for illustrative purposes only, zone of inhibition testing results can vary. Antibacterial Suture shown in vitro to inhibit bacterial colonization of the suture for 7 days or more

Recommendations for CLABSI reduction practices from Healthcare Infection Control Practices Advisory Committee of Centers for Disease Control and Prevention RECOMMENDATION Hand hygiene prior to catheter insertion All inclusive catheter carts or kits Maximal sterile barrier precautions Chlorhexidine for skin anti-sepsis Antimicrobial catheters Subclavian vein insertion Disinfect hubs and needle-less connectors Remove non-essential CVCs Chlorhexidine cleansing CVC (transparent film) dressing CLASSIFICATION Category IB Category IB Category IB Category IA Category IA Category IB Category IA Category IA Category II Category IA Chlorhexidine impregnated sponge dressing Category 1B Topical antibiotic use (dialysis) Antibiotic or anti-infective locks Educational interventions Catheter bundles or checklists Use of specialized CVC insertion teams Prevention of Central Line-Associated Bloodstream Infections: Brief Update Review. US National Library of Medicine. https://www.ncbi.nlm.nih.gov/books/nbk133364/ Accessed 4/25/17 Category IB Category II Category IA Category IB Category IA

Revised CHG Impregnated Dressings Recommendation 1. For patients aged 18 years and older: a. Chlorhexidine-impregnated dressings with an FDA-cleared label that specifies a clinical indication for reducing catheter-related bloodstream infection (CRBSI) or catheter-associated bloodstream infection (CABSI) are recommended to protect the insertion site of short-term, non-tunneled central venous catheters. (Category IA) 2017 Updated Recommendations on the Use of Chlorhexidine-Impregnated Dressings for Prevention of Intravascular Catheter-Related Infections. CDC.gov. https://www.cdc.gov/infectioncontrol/guidelines/pdf/guidelines/c-i-dressings.pdf Accessed 11/7/17

Some of the evidence cited by the CDC support the recommendation

Areas of Opportunity Rebaselining Central Venous Catheters Dialysis Catheters Arterial Catheters PICC Lines Peripheral IVs Mid Lines Epidural Catheters Implanted Venous Ports External Fixator Pins Drains HAI Progress Report FAQ. Centers for Disease and Control website. www.cdc.gov. Accessed 11/8/17

Interesting case study Methodist Hospitals of Northwest Indiana aligned their Peripheral IV (PIV) policy to INS Standards of Practice, moving from the routine replacement of PIVs to clinically indicated replacement of PIVs. They proactively protected the lines by implementing a PIV bundle (education, Protective Disk with CHG, securement dressing, alcohol impregnated caps, integrated closed IV catheter system and sterile gloves) and tracked their data for 12 months to understand the impact of these changes. The hospitals realized a: 37% reduction in house-wide laboratory confirmed bloodstream infections 19% reduction in peripheral IV-related BSIs 2 Years Post Implementation Sustained 6% Further Reduction 68% fewer CLABSIs than predicted via NHSN Sustained DeVries M, Valentine M. Mancos P. Protected Clinical Indication of Peripheral Intravenous Lines: Successful Implementation. Journal of Vascular Access. June 2016. Volume 21, Issue 2, Pages 89 92

Summary Antibiotics have become an integral part of healthcare and have had a tremendous impact on our very existence Antibiotic resistance poses a real threat to the treatment of disease as we know it We can take steps to break the chain of infection to help mitigate the problem

Summary Antibiotics have become an integral part of healthcare and have had a tremendous impact on our very existence Antibiotic resistance poses a real threat to the treatment of disease as we know it We can take steps to break the chain of infection to help mitigate the problem Prevent infections from catheters and after surgery Prevent bacteria from spreading + = Reduce or eliminate antibiotic use Break the chain of infection with the use of evidenced based products Follow good clinical practice

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