POTENTIAL STRUCTURE INDICATORS FOR EVALUATING ANTIMICROBIAL STEWARDSHIP PROGRAMMES IN EUROPEAN HOSPITALS Dirk VOGELAERS Department of General Internal Medicine, Infectious Diseases and Psychosomatic Medicine Utrecht, June 21 st 2013 1
Survey in European hospitals (n= 170 in 32 countries): observational cross-sectional study performed from Jan 2002 until June 2005 2 2
DTC = drugs and therapeutics committee. Bruce J et al, J Antimicrob Chemother 2009;64:853-60 3 3
Survey in European hospitals (ctd) Bruce J et al, J Antimicrob Chemother 2009;64:853-60 4 4
Policies and practices relating to antibiotic stewardship varied considerably across European hospitals Baseline data serving as a benchmark Considerable room for improvement and harmonization of recommended practice No identification of any significant relationship between these selected key stewardship criteria and total antibiotic consumption Bruce J et al, J Antimicrob Chemother 2009;64:853-60 5 5
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Background (1) Worldwide increasing antibiotic resistance. European Council: recommendation (2001) on the prudent use of antimicrobial agents in human medicine (focus on surveillance of antimicrobial resistance and use, control and preventive measures, education and training, research). project proposal implementing antibiotic strategies (ABS) for appropriate use of antibiotics in hospitals in member states of the European Union ABS International (presented to the EU Commission in 2005). start of the project in 2006 with implementation in 9 member states (Austria, Germany, Belgium, Italy, Poland, Hungary, Czech Republic, Slovenia and Slovakia). Buyle FM et al, Eur J Clin Microbiol 2013, published on line 7 7
Background (2) Development of structure and process indicators for evaluating activities of antimicrobial stewardship committees/antimicrobial management teams with quality assessment tools for evaluating activities. Structural indicators: describe organisation and resources, communication and evaluation tools available at hospital level for implementing a multimodal, multi-disciplinary stewardship programme. must focus on antimicrobial drug prescribing and administration in hospital care, with reference to national standards and international, national or local practice guidelines. Objective: optimising individual patient care. ecological dimension (minimise risk of resistance selection and spread). Buyle FM et al, Eur J Clin Microbiol 2013, published on line 8 8
Development of structure indicators International multi-disciplinary team: 5 infectious disease specialists. 2 clinical microbiologists. 3 hospital pharmacists. 3 quality of health care experts. 3-step process: identification of candidate quality indicators based on scientific literature. scoring and ranking of the listed quality indicators based on perceived scientific value and applicability. selection of quality indicators by consensus. Buyle FM et al, Eur J Clin Microbiol 2013, published on line 9 9
Buyle FM et al, Eur J Clin Microbiol 2013, published on line 10 10
Selection of quality indicators (1). Definition: measurable aspect of care provided for which there is evidence and/or consensus that it represents quality on the grounds of scientific research or consensus among experts (Lawrence M et al, Eur J Gen Pract 1997;3:103-8). 74 potential indicators identified. 58 indicators selected: antimicrobial stewardship services (n=12). tools (n=16). human resources and mandate (n=6). health care personnel development (n=4). basic diagnostic capabilities (n=6). microbiological rapid tests (n=2). evaluation of microbiological data on antobiotic resistance (n=3). antibiotic consumption control (n=5). drug use monitoring (n=4). Buyle FM et al, Eur J Clin Microbiol 2013, published on line 11 11
Selection of quality indicators (2). Identification of top-10 indicators with the highest score for ranking + applicability: 1. bedside expert consultant advice regarding antibiotics on request available same day (services). 2. regular ward rounds by members of the antibiotic management team (services). 3. clinical audit of prescribers compliance with local guidelines performed by member of the antibiotic management team (service). 4. antibiotic formulary/list available and updated biannually (tool). 5. local clinical practice guidelines for empirical therapy available and updated biannually (tool). Buyle FM et al, Eur J Clin Microbiol 2013, published on line 12 12
Selection of quality indicators (3). 6. local clinical practice guidelines for microbiologically documented therapy available and updated biannually (tool). 7. local clinical practice guidelines for surgical antibiotic prophylaxis available (tool). 8. formal mandate for hospital multi-disciplinary antibiotic management team existing (human resources and mandate). 9. member of the antibiotic management team is member of the drugs and therapeutics committee (human resources and mandate). 10. prescriber education by personalised interactive methods (daily ward rounds) performed (personnel development). Buyle FM et al, Eur J Clin Microbiol 2013, published on line 13 13
Validation survey. Pilot study in 11 hospitals (7 university and 4 general): 280 to 2,392 beds. 9 to 132 ICU beds. Results: scores from 32 to 50/58 when taking all indicators into account. scores from 5 to 10/10 when taking selected indicators into account. Buyle FM et al, Eur J Clin Microbiol 2013, published on line 14 14
Buyle FM et al, Eur J Clin Microbiol 2013, published on line 15 15
Buyle FM et al, Eur J Clin Microbiol 2013, published on line 16 16
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400-800 Van Gastel E et al, J Antimicrob Chemother 2010;65:576-80 18 18
ABS project Structure indicators: 58 selected (with top ten) Process indicators (11) Prophylaxis: 4 selected Surgical prophylaxis (4) Antibiotic prophylaxis given perioperatively for surgical interventions when indicated Appropriate antibiotic choice for prophylaxis for surgical interventions according local guidelines Prophylaxis is started preoperatively within 60 minutes before incision for surgical interventions Prophylactic antibiotic is discontinued within 24 hours after surgery end time 19 19
ABS project Therapy: 7 selected CAP (3) Performing blood cultures within the first 24 hours after admission in CAP patients Appropriate empiric therapy for CAP according to local practice guideline Performing Legionella urinary antigen test within 24 hours after admission in CAP patients IV/PO switch (1) Inappropriate fluoroquinolones, clindamycin, linezolid, metronidazole treatment by IV route according to local IV/PO switch guidelines SAB (3) 20 20
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Indicator: proportion of inappropriate iv treatments at any point in time in adult patients treated with fluoroquinolones, clindamycin, linezolid and metronidazole. Prospective evaluation of treatments by a trained physician or clinical pharmacist using preferred clinical criteria. Feasibility of the indicator evaluated by measuring data availability, data collection workload and sensitivity of improvement. University hospitals (2 in Austria, 2 in Belgium, 1 in Germany). Buyle FM et al, J Antimicrob Chemother 2012;67:2043-6 22 22
Buyle FM et al, J Antimicrob Chemother 2012;67:2043-6 23 23
Key findings. > 99% of required data readily available. Workload per patient : 29 minutes. Substantial heterogeneity of performance gap. Hospitals (n=2) with an iv to po switch improvement programme score significantly better. Substantial sensitivity to improvement. Improvement programme in 2 hospitals: educational letters, poster campaigns, support by trained physicians/pharmacists. More inappropriate treatments in medical patients than in surgical patients. Highest proportion of inappropriate treatments in patients with skin, soft tissue, bone or joint infections. => Indicator is widely applicable in acute care hospitals. Buyle FM et al, J Antimicrob Chemother 2012;67:2043-6 24 24
Staphylococcus aureus bacteraemia: 3 indicators Number of patients who have undergone echocardiography (Trans-oesophageal echocardiography (=TEE) or Transthoracic echocardiography (TTE ) within 10 days after SAB onset versus all community-onset SAB Patients who have their iv catheter (peripheral or central) present at SAB onset removed within 10 days after SAB onset versus patients with iv catheters in place at SAB onset (including confirmed and possible catheter-related infection) MSSAB patients receive 10 days of iv betalactam (penicillinase-stable in the case of penicillin resistance) therapy within 14 days of SAB onset versus all patients with MSSAB 25 25
Staphylococcus aureus bacteraemia: retrospective observational study Number of cases: 500 in 9 hospitals (3 Austria, 2 Belgium, 1 Czech Republic, 2 Germany, 1 Slovenia) Ratio female/male: 199/301 Mean age (SD): 61,5 (17.6) Workload for measuring CRF 26 min/crf 26 26
Staphylococcus aureus bacteraemia: results indicator 1 27 27
Staphylococcus aureus bacteraemia:type of echo performed 28 28
Staphylococcus aureus bacteraemia: results indicator 2 29 29
Staphylococcus aureus bacteraemia: results indicator 2 Device type Numerator Denominator Indicator rate Peripheral catheter 50 76 65,80 Central catheter 74 90 82,20 Permanent implanted catheter 26 51 51 cardiac pacemaker 4 10 40 other devices (e.g. shunt, prosthetic heart valve) 10 37 27 30 30
Staphylococcus aureus bacteraemia: results indicator 3 31 31
Conclusion For S. aureus bacteraemia management, the QI bundle with the largest sample, median indicator rates ranged from 60 to 65%, with major interhospital performance variation. This indicates that these clinical procedures remain challenging in all centres All three QI were demonstrated to be generally feasible in the participating centres from 5 countries, reliable to measure in spite of the diverse expertise of data reviewers, and informative about local needs for further improvement towards the best standards of care. Data collection workload appeared reasonable (1 to 3 days working time by bundle). 32 32
Results Ghent University Hospital 33 33
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Cartoos et al 2011 (submitted) 36 36
From gross structure indicators to probing operational process indicators A multidisciplinary effort of medical microbiologists + clinical pharmacy + infectiologists may prove insufficient Problem of impacting on habits and behavior Maybe a next step will be to involve behavorial scientists and even marketing specialists in order to get logical concepts across the mind and into practice: an enlarged team may be a structure indicator for the future Superior level of outcome indicators probably even more difficult to achieve (problems of comparability, patient mix) 37 37