Linda Taggart MD FRCPC Infectious Diseases Physician Lead Physician, Antimicrobial Stewardship Program St. Michael s Hospital

no industry conflicts of interest salary support to lead Antimicrobial Stewardship Program, St. Michael s Hospital

introduction to audit and feedback discuss practical aspects of performing audit and feedback outline our approach at St. Michael s Hospital share what I ve learned

patient-specific review & recommendations to prescriber most responsible physician maintains prescribing autonomy *in contrast with pre-authorization or restriction*

unnecessary antimicrobial use leads to preventable harm development of resistance increased colonization with resistant organisms C. difficile infection other adverse events inadequate initial antimicrobial therapy associated with reduced survival in septic shock 1 *up to 50% of antimicrobial use is inappropriate* 2 1 Kumar, A. Chest. 2009 Nov;136(5):1237-48. 2 Dellit, TH. Clin Infect Dis. 2007 Jan 15;44(2):159-77.

ICUs: predominantly quasi-experimental prepost intervention statistically significant reductions in: antimicrobial use (11-38%) duration of antimicrobials antimicrobial costs (24-36%) improvements in: appropriateness of therapy nosocomial C. difficile infection rates susceptibility of Gram negative organisms Rimawi, RH. Crit Care Med. 2013 Sep;41(9):2099-107.; Elligsen, M. Infect Control Hosp Epidemiol. 2012 Apr;33(4):354-61; Katsios, CM. Crit Care. 2012 Nov 5;16(6):R216.; Leung, V. Can J Hosp Pharm. 2011 Sep;64(5):314-20.; Marra, AR. Am J Infect Control. 2009 Apr;37(3):204-9.; Solomon, DH. Arch Intern Med. 2001 Aug 13-

Which patients to review? Who is involved? How are recommendations provided? (How to track progress?)

majority of ICU-specific programs review all patients or all patients on antimicrobials 1-3 downside: time consuming 1 Rimawi, RH. Crit Care Med. 2013 Sep;41(9):2099-107. 2 Katsios, CM. Crit Care. 2012 Nov 5;16(6):R216. 3 Leung, V. Can J Hosp Pharm. 2011 Sep;64(5):314-20.

broad-spectrum antibiotics 1-2 specific duration of antimicrobial use 1 1 Elligsen, M. Infect Control Hosp Epidemiol. 2012 Apr;33(4):354-61. 2 DiazGranados, CA. Am J Infect Control. 2012 Aug;40(6):526-9

Wong, JR. Ann Pharmacother. 2012 Nov;46(11):1484-90.

Avdic, E. Clin Infect Dis. 2012 Jun;54(11):1581-7.

Hermsen, ED. Infect Control Hosp Epidemiol. 2012 Apr;33(4):412-5.

Core Antimicrobial Stewardship team: infectious diseases physician clinical pharmacist with infectious diseases training

Multidisciplinary involvement: Director of Pharmacy Director of Infection Control Division Head of Infectious Diseases Director of Microbiology Champions: Division Head for Critical Care Executive level support

Intensivists/fellows/residents ICU pharmacists

chart recommendations communication with ICU team (in person or any route) Rimawi, RH. Crit Care Med. 2013 Sep;41(9):2099-107. Elligsen, M. Infect Control Hosp Epidemiol. 2012 Apr;33(4):354-61 DiazGranados, CA. Am J Infect Control. 2012 Aug;40(6):526-9 Teo, J. Eur J Clin Microbiol Infect Dis. 2012 Jun;31(6):947-55. Leung, V. Can J Hosp Pharm. 2011 Sep;64(5):314-20.

historically many centres avoided permanent records of advice 1-2 some centres (especially Canadian centres) have used permanent documentation 3 many do not document at all (discussion only) 4-5 1 Fraser, GL. Arch Intern Med. 1997 Aug 11-25;157(15):1689-94. 2 LaRocco, A. Clin Infect Dis. 2003 Sep 1;37(5):742-3. 3 Elligsen, M. Infect Control Hosp Epidemiol. 2012 Apr;33 4 Rimawi, RH. Crit Care Med. 2013 Sep;41(9):2099-107. 5 Leung, V. Can J Hosp Pharm. 2011 Sep;64(5):314-20.

working with TNICU (19 beds) and MSICU (24 beds) stewardship physician and pharmacist review all patients every weekday (EPR only) dedicated antimicrobial stewardship rounds with ICU team daily (30 min maximum) recommendations predominantly verbal ICU team free to take or leave suggestions

formal evaluation planned for 1 year preliminary results at 6 months

18% reduction in overall antimicrobial use 25% reduction in anti-pseudomonals 89% reduction in fluoroquinolones (no change in mortality, LOS, 48hr readmission)

no significant change in overall antibiotic use 11 fold increase in mean cystic fibrosis patient days per month Success?

one size doesn t fit all ICU team should play a key role in program design strong support from champions is key

face-to-face meeting has numerous advantages most up-to-date clinical information opportunity for ICU team to share concerns reviewing all patients is useful empiric therapy to start prevent unnecessary starts work collaboratively with ID team resource intensive

Rimawi, RH. Crit Care Med. 2013 Sep;41(9):2099-107.