APIC E-Learning Labs EXPERT TEACHING SESSIONS 1
Antimicrobial Stewardship: What the Infection Preventionist Needs to Know Keith S. Kaye, MD, MPH Corporate Vice President of Quality and Patient Safety Corporate Medical Director, Infection Prevention, Hospital Epidemiology and Antimicrobial Stewardship Detroit Medical Center and Wayne State University Detroit, MI Overview What is antimicrobial stewardship and who makes up the stewardship team? How can infection prevention and control interface and collaborate with antimicrobial stewardship? Future opportunities and challenges 2
Learning Objectives State the definition and goals of antimicrobial stewardship Describe the components of an antimicrobial stewardship program Discuss the role and collaboration of the Infection Preventionist with an antimicrobial stewardship team The State of Antimicrobial Resistance and Antimicrobial Stewardship Antibiotic resistance continues to emerge and disseminate Industrial pipeline for new antimicrobials is dry We are often stuck with the hand we have been dealt when treating multi-drug resistant organisms (MDROs) Antimicrobial stewardship has become critically important The Joint Commission, CMS, State of California have each focused on Antimicrobial Stewardship 3
12 Steps to Prevent Antimicrobial Resistance: Hospitalized Adults Prevent Infection Use Antimicrobials Wisely 1. Vaccinate 5. Practice antimicrobial control 2. Get the catheters out 6. Use local data 3. Target the pathogen 4. Access the experts Centers for Disease Control and Prevention. Available at: http://www.cdc.gov/drugresistance/ healthcare/ha/12steps_ha.htm. Accessed Nov. 10, 2010. 7. Treat infection, not contamination 8. Treat infection, not colonization 9. Know when to say no to vanco 10. Stop treatment when infection is cured or unlikely Prevent Transmission 11. Isolate the pathogen 12. Break the chain of contagion Empiric Antimicrobial Therapy : A Balancing Act Rapid, effective therapy Unnecessary therapy, Collateral damage 4
Antimicrobial Stewardship Appropriate use of antimicrobials The right agent, dose, timing, duration, route Optimize clinical outcomes Optimize time to effective therapy Limit drug-related adverse events Minimize risk of unintentional consequences Help reduce antimicrobial resistance The combination of effective antimicrobial stewardship and infection control has been shown to limit the emergence of antimicrobialresistant bacteria Dellit TH et al. Clin Infect Dis. 2007;44(2):159 177;. Drew RH. J Manag Care Pharm. 2009;15(2 Suppl):S18 S23; Drew RH et al. Pharmacotherapy. 2009;29(5):593 607. 5
Why Participate in Stewardship The primary goal of stewardship is to Optimize clinical outcomes while minimizing unintended consequences of antimicrobial use, including toxicity, the selection of pathogenic organisms, and emergence of resistance. Secondary goals Reduce healthcare costs without adversely impacting quality of care. Dellit TH et al. Clin Infect Dis 2007;44:159-77 Key Members of the Team Two major components: a) expertise and leadership and b) key stakeholders/major users/local leaders Experts and Hospital Leadership Infectious Diseases physician(s) (compensated) ID Pharmacist (compensated) Microbiology Administration (support, agree with metrics and goals) Informatics support Key stakeholders/major users/local leaders Critical Care Emergency Medicine Infection Control Nursing Clinical pharmacy Hospitalists P and T 6
Antimicrobial Stewardship Reporting and Structure Antimicrobial stewardship committees usually report/serve as a subcommittee to Pharmacy and Therapeutics Key members include Infectious Diseases physician, Infectious Diseases pharmacist Often support and collaboration with Infection Control Communication and collaboration with ID, pharmacy, P and T and clinicians critical for success Formulary Restriction/Pre-authorization Up front before the train leaves the station Formulary restrictions/pre-authorization for specific antibiotics Other less rigid up front options Criteria monitored antibiotics/clinical indications (eg follow-up/monitoring by ID-Pharmacists Guidelines and clinical pathways can be very effective if local leadership is vested in success (eg VAP pathway in an ICU) Pros: stop overuse before it starts; potential for tight control Cons: Labor intensive; culture in some hospitals will limit up-front control; difficult to convince providers to limit empiric broad spectrum coverage in acutely ill patients; antimicrobial resistance complicates empiric antimicrobial therapy 7
Audit with Feedback Monitor empiric use and help guide, but less restriction Might targets downstream opportunities de-escalation opportunities, shortening duration Pros less confrontation, conflict during empiric treatment phase Cons durations can get lost in the shuffle in complex patients; if patients are doing well providers sometimes resistant to change * ATS/IDSA guidelines, AJRCC, 2005; Dunbar, CID, 2003 De-escalation De-escalation is the modification of empiric antimicrobial therapy on the basis of culture results and elimination of redundant therapy More effectively target the causative pathogen(s) Decrease antimicrobial pressure - - > emergence of resistance Associated with cost savings Can also base de-escalation on clinical criteria and/or negative culture results Dellit TH et al. Clin Infect Dis. 2007;44:159-177. 8
Why De-escalate? De-escalation of empiric therapy is an important opportunity to discontinue antimicrobial agents and avoid unnecessary antimicrobial exposure to colonizing bacteria Due to increasing prevalence of antimicrobial resistance in healthcare and community settings, and a growing population of medically complex patients, broad-spectrum empiric antimicrobial therapy is often necessary De-escalation is an opportunity to eliminate unnecessary coverage at an early stage of therapy Decreasing the number and/or spectrum of coverage not only decreases the risk for antimicrobial resistance, but also can decrease the risk for adverse events, drug-drug interaction and Clostridium difficile Dellit TH et al. Clin Infect Dis. 2007;44:159-177. Paterson DL et al. Clin Infect Dis. 2008;47(suppl 1):S14-20. De-escalation strategy In most cases, empiric therapy should be narrowed at day 3-4 or earlier If cultures are negative, narrow regimen If cultures are positive, usually can focus regimen Pseudomonas, MRSA coverage often opportunities Often, empiric antibiotics are continued due to inertia, complicated clinical picture Reminders at day 3-4 for multi-antimicrobial antibiotic regimens aggressive efforts to decrease number, duration of antibiotics 9
Duration of Antimicrobial Therapy Appropriate duration of therapy established for some Infections Group A Strep pharyngitis, UTIs, some STDs, endocarditis Sufficient data supporting appropriate duration of antimicrobial therapy for many infections are lacking Recent studies indicate shorter course antimicrobial therapy effective for CAP, HAP/VAP Evidence-based guidelines recommend shorter course therapy for intra-abdominal infections and specify duration for catheterrelated bacteremia Craven DE et al. Shorter course antibiotic therapy. In: Owens and Lautenbach, eds. Antimicrobial Resistance. Informa Healthcare, NY; 2008. Duration of Antimicrobial Therapy Advantages of SHORT(ER) antimicrobial therapy Lower cost Less toxicity Better adherence Reduced antimicrobial resistance High cure rates are possible with short-course therapy when pharmacodynamic principles are used Concentration-dependent effect Time-dependent effect Concept: Hit hard and fast then leave ASAP 1 Consider PK/PD parameters 1. File T. Clin Infect Dis. 2004;39(Suppl 3):S159-164. 10
Components of Optimal and Appropriate Antimicrobial Use Optimal agent, optimal dose, optimal duration 1 World Health Organization (WHO) Report on Infectious Diseases, 2000: Overcoming Antimicrobial Resistance 2,3 Treat more aggressively with shorter courses to help reduce antibiotic resistance 1.Polk R. Clin Infect Dis. 1999;29:264-274. 2.World Health Organization Report. Available at: http://www.who.int/infectious-diseasereport/2000/index.html. 3.Perez-Gorricho B. Int J Antimicrob Agents. 2003;21:222-228. A Rational Stewardship Strategy Broad spectrum therapy for empiric treatment of suspected invasive nosocomial infection Rapid de-escalation by day 3-4 When possible, short durations of in-hospital antibiotics for selected populations Avoid anti-pseudomonal agents when possible (eg type 1 carbapenam) Hit hard, de-escalate, get out 11
Important Concepts for Antimicrobial Stewardship Be aggressive plenty of opportunities, but can t be passive As your perceived value and import increase, so does the pressure, meetings and expectations Think outside of the box Processes of care that impact antimicrobial prescribing Appropriate culturing and testing Reporting of results Rapid diagnostics Antiseptics (ie chlorhexidine?) Vaccination? Resources and support are critical Don t go beyond the call of duty without formal support Infection Control Antimicrobial Stewardship Collaboration Opportunities Influenza/emerging infections Device-related infections Abx resistance/c. diff Operative care Bloodborne fluid exposures Regulatory/accreditation QI/Patient Safety Ambulatory care Communicable diseases Tuberculosis P4P/CMS Environment 12
Antimicrobial Resistance Minimizing unnecessary antimicrobial use can prevent the emergence and spread of multi-drug resistant (MDR) Gram-negative bacilli ESBL-producers, Carbapenem-resistant, enterobacteriaceae, MDR Pseudomonas aeruginosa, MDR Acinetobacter baumannii Methods Treatment guidelines and protocols De-escalation Short durations of therapy Dellit TH et al. Clin Infect Dis. 2007;44:159-177; Paterson DL et al. Clin Infect Dis. 2008;47(suppl 1):S14-20; Craven DE et al. Shorter course antibiotic therapy. In: Owens and Lautenbach, eds. Antimicrobial Resistance. Informa Healthcare, NY; 2008; File T. Clin Infect Dis. 2004;39(Suppl 3):S159-164;. Marchaim, Infect Control Hosp Epidemiol. 2012;33(8):817-30 De-escalation Strategy to Limit Type 2 Carbapenem Use Goal: limit Type 2 carbapenem use (doripenem, imipenem, meropenem) Reduce selective pressure on Pseudomonas aeruginosa, Acinetobacter baumannii and carbapenem-resistant entoerbacteraiaciae Intervention Utilize non-carbapenem antibiotics if culture negative, patient not in ICU If susceptible enterobacteriaciae are isolated If carbapenem use necessary, utilized ertapenem instead of type 2 carbapenems Infections due to ESBL, AmpC hyperproducer Simulated impact of a program implemented at 3 hospitals in 2009 (1311 beds) Pogue ECCMID, 2012 13
Analysis of the potential impact of a formalized carbapenem de-escalation program Indication for group 2 carbapenem therapy Patients receiving group 2 carbapenems (n=599) Patient days of group 2 carbapenem use (n=3306) Infection due to ESBL, ampc hyperproducer, or more susceptible enterobacteriaceae 101 (17%) 598 (16%) Cultures (-) patient not in ICU 75 (13%) 476 (12%) Total 176 (30%) 1074 (28%) Pogue ECCMID, 2012 Hospital-acquired conditions for potential reduced payment: Finalized by CMS in 2008 Catheter-associated urinary tract infections Vascular catheter-associated blood stream infection (BSI) CMS now has a specific code for central-line vascular catheters (CVC) Surgical site infection Mediastinitis after CABG surgery. This infection has a specific complication code Selected orthopedic surgeries Spinal fusion and other surgeries of the shoulder and elbow Bariatric surgery for morbid obesity - laparoscopic gastric bypass and gastroenterostomy www.cms.gov 14
CMS - Value Based Purchasing Program P4P program that links Medicare payment to the quality performance of hospitals Performance period began July, 2011 Payments effected beginning FFY 2013 Will be phased in over a 3 years CMS will calculate two scores for each measure An achievement score and an improvement score A final score for each measure will be the higher of the two scores Scores based on process of care, patient experience and outcomes http://www.cms.gov/hospitalqualityinits/downloads/0210_slides.pdf VBP Process of Care Measures PN 3b -Blood Cultures Performed in the ER Prior to Initial Antibiotic received in hospital. PN 6-Initial Antibiotic Selection for CAP in Immunocompetent Patient SCIP Inf-1 -Prophylactic Antibiotic Received Within 1 Hour Prior to Surgical Incision SCIP Inf-2 -Prophylactic Antibiotic Selection for Surgical Patients SCIP Inf-3 -Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery SCIP Inf-4 -Cardiac Surgery Patients w/ Controlled 6AM Postoperative Serum Glucose https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/hospital-value-basedpurchasing/index.html?redirect=/hospital-value-based-purchasing/ 15
VBP Outcome Measures (FFY 2014) Mortality Measures AMI 30 day mortality HF 30 day mortality PN 30 day mortality AHRQ PSI and IQI Composite Measures Complication/patient safety for selected indicators (composite) Mortality for selected medical conditions (composite) HAC Measures Foreign Object Retained After Surgery Air Embolism Blood Incompatibility Pressure Ulcer Stages III & IV Falls and Trauma (fracture, dislocation, intracranial injury, burn, electric shock) Vascular Catheter Associated Infections Catheter Associated Urinary Tract Infection (UTI) Manifestations of Poor Glycemic Control Medicare Payment Cuts and Payment Adjustments Percentile (score as compared to others) 16
CMS and Re-admissions Traditionally all-cause readmissions tracked for Pneumonia CHF AMI Now re-admissions for most DRGs are measured Financial incentive for low 30 day readmission rates CMS Other Reported Conditions (On Deck for VBP?) SSI Colon, hysterectomy, hip and knee arthroplasty Re-admissions and complications - Hip and knee arthroplasty Vaccinations Patients: Pneumococcal, Influenza Staff: Influenza Resistant organisms Methicillin-resistant Staphylococcus aureus (MRSA) Clostridium difficile 17
The Double-Edged Sword of CMS One side: extra work, extra pressure Other side: increased focus, value from hospital leadership perspective For the first time, opportunities to help hospitals earn more money HAIs, compliance with prevention processes more visible to public Infection Control is in a unique position to gain influence, leverage and improve hospital care Infection Control can best achieve these goals through strategic collaborations Synergistic Collaborations Focusing on CMS Metrics involved in Value Based Purchasing (VBP) and/or reported to CMS are among most visible, important conditions and processes to administration and clinical leadership If you want to be visible and valued, help to improve/optimize VBP/CMS metrics Several potential collaborations for infection control and antimicrobial stewardship These issues can be better addressed via collaborations between infection control and antimicrobial stewardship than by either group individually Plenty of work to go around! The more the merrier... 18
Operative Care Prevention of surgical site infection Orthopedic (implant) surgeries (HPRO, KPRO) CABG Bariatric surgery Prevention of surgical site infection due to MRSA Role of antimicrobial stewardship team Appropriate antimicrobial prophylaxis dosing (and redosing) Pre-operative screening for S. aureus and decolonization/changes in antimicrobial prophylaxis Prevention of Infection Due to S. aureus in Surgery Involving Implants Complex, multi-step process Screening patients in timely, pre-operative fashion Follow-up on results Prescription and education re: decolonization with mupirocin and chlorhexidine Appropriate changes in pre-operative antimicrobial prophylaxis (ie for MRSA carriers) Infection control, surgeons can use help in establishing and executing these processes! Bode, NEJM, 2010, vol 362, p 9-17 19
Multi-drug Resistant Organisms and CMS MRSA prevention Antimicrobial interventions (eg eliminating unnecessary fluoroquinolone use) Pre-operative screening, decolonization, antimicrobial prophylaxis C. difficile infection Diagnostics Avoiding antimicrobial overuse Other CMS-Related Collaborative Opportunities Pneumonia core measures Blood cultures Appropriate antimicrobials Readmissions (Pneumonia) SCIP antimicrobial prophylaxis Central-line associated bloodstream infection Appropriate culturing avoiding cultures drawn through the catheter, avoiding unnecessary blood cultures Catheter-associated urinary tract infection Avoiding unnecessary cultures of urine Avoiding unnecessary treatment of asymptomatic bacteruria Vaccination of patients and healthcare providers 20
Navigating the Political Healthcare Landscape Infection control is immersed in regulation, public/cms reporting and healthcare politics Routine reporting and cross-reporting with CMO Quality and Patient Safety Occupational Health Environmental Services Operative care team Sterilization and high-level disinfection Pharmacy Emergency room Nursing Medical Executive Committee Clinical Microbiology Critical care Navigating the Political Landscape (2) Infection control can assist antimicrobial stewardship with Understanding lines of reporting Business case and ROI development Identifying and avoiding political landmines Identifying and interacting with influential administrators, clinicians, thought leaders Who to avoid Timelines and processes for development and implementation of protocols, guidelines, interventions, changes in practice/culture 21
Conclusions Infection control is well established in hospital culture and infrastructure Antimicrobial stewardship is emerging and increasingly recognized and valued Many opportunities for fruitful collaborations and interactions between infection control and antimicrobial stewardship Antimicrobial resistance and C. difficile Operative care CMS reporting and VBP Antimicrobial stewardship can learn much from infection control with regards to navigating the political healthcare landscape To obtain your certificate, please click the Evaluation Link: http://webinars.apic.org/evaluation/index.p hp?id=10162 and enter the certificate code below: UpaQB8 22
23