Antimicrobial Stewardship: Stopping the Spread of Antibiotic Resistance Natalie Weber, PharmD PGY2 Critical Care Pharmacy Resident September 22, 2016 The speaker has no actual or potential conflicts of interest in relation to this presentation.
Get Smart for Healthcare. Available at: http://www.cdc.gov/getsmart/healthcare/evidence.html. Accessed 2016 Jul 25. Lawrence KL et al. Am J Respir Crit Care Med 2009;179:434-8. Antimicrobial Stewardship An antibiotic is the only drug where use in one patient can impact the effectiveness in another Antimicrobial Stewardship Control Costs Improve Clinical Outcomes Combat Resistance
A Role for Stewardship Executive Order 13676 Sept 2014 Sept 2014 National Strategy for Combating Antibiotic- Resistant Bacteria (CARB) CDC Core Elements of Hospital Antimicrobial Stewardship Programs 2014 Mar 2015 National Action Plan for Combating Antibiotic- Resistant Bacteria Presidential Advisory Council appointed for Combating Antibiotic Resistant Bacteria (PAC-CARB) Sept 2015 Jan 2017 The Joint Commission Antimicrobial Stewardship Standard (MM 09.01.01) End of 2017 CMS Conditions of Participation
New Antimicrobial Stewardship Standard. Available at: https://www.jointcommission.org/assets/1/6/new_antimicrobial_stewardship_standard.pdf. Accessed 2016 Jul 25. 1: Leaders establish antimicrobial stewardship as an organizational priority Basic Obtain formal board approved statement Publish newsletter column Secure salary support Intermediate Create a facility-wide strategic dashboard item Design ongoing provider education Host speakers/events Advanced Fund new technology Provide incentives for unit/departmental improvement Barrier -Lack of support -Low level of awareness -Initiative fatigue -Share statistics and statements of importance -Inform regarding regulatory requirements -Collect hospital-specific data Solution
New Antimicrobial Stewardship Standard. Available at: https://www.jointcommission.org/assets/1/6/new_antimicrobial_stewardship_standard.pdf. Accessed 2016 Jul 25. Basic 2: Educate practitioners involved in ordering, dispensing, administration, and monitoring about antimicrobial resistance and stewardship Publish quarterly updates in employee newsletter Intermediate Present Grand Rounds Educate staff on resistance and microbiology data interpretation Advanced Require yearly competency training Include stewardship elements in new hire orientation Barrier -Time constraints -Poorly engaged audience -Difficult to measure effectiveness -Train champions from multiple disciplines -Utilize specific, timely patient cases -Incorporate post-tests and specific feedback Solution
3. Educate patients and families regarding the appropriate use of antimicrobial medications Get Smart for Healthcare. Available at: http://www.cdc.gov/getsmart/healthcare/evidence.html. Accessed 2016 Jul 25. New Antimicrobial Stewardship Standard. Available at: https://www.jointcommission.org/assets/1/6/new Antimicrobial Stewardship Standard.pdf. Accessed 2016 Jul 25.
New Antimicrobial Stewardship Standard. Available at: https://www.jointcommission.org/assets/1/6/new_antimicrobial_stewardship_standard.pdf. Accessed 2016 Jul 25. 4. Have an antimicrobial stewardship multidisciplinary team that includes the following Infectious Diseases Physician Pharmacist(s) AST Practitioner(s) Infection Preventionist(s)
New Antimicrobial Stewardship Standard. Available at: https://www.jointcommission.org/assets/1/6/new_antimicrobial_stewardship_standard.pdf. Accessed 2016 Jul 25. 5. Hospital s antimicrobial stewardship program should include the following core elements D CDC CDC Core Element Core Element TJC Element of Performance Leadership Leadership Commitment Commitment 1 Accountability Accountability 4 Drug Expertise Drug Expertise 4 Action Action 6 and 8 Tracking Tracking 7 Reporting Reporting 7 Education Education 2 and 3
New Antimicrobial Stewardship Standard. Available at: https://www.jointcommission.org/assets/1/6/new_antimicrobial_stewardship_standard.pdf. Accessed 2016 Jul 25. 6. Hospital s antimicrobial stewardship program uses organization-approved multidisciplinary protocols Pharmacy to dose protocols Facility-specific treatment recommendations EMR based order sets D Eskenazi Health Recommended Empiric Antibiotic Regimens by Infection for Adult Patients Severe Sepsis Infection and Suspected Organism Recommended Regimen Alternative Regimen Vancomycin Community Acquired Pneumonia Streptococcus pneumoniae, Haemophilus influenzae, Legionella pneumophila, etc Pseudomonas aeruginosa consider in patients with structural lung disease, recent hospitalization, recent antibiotic therapy, or need for ICU admission Amnioglycoside Pneumonia Ceftriaxone + Azithromycin Pipercillin/Tazobactam + Azithromycin (+/- Tobramycin or Ciprofloxacin if additional gram negative coverage needed) CRRT Dose Adjustments C. difficile Levofloxacin Cefepime + Azithromycin (+/- Tobramycin or Ciprofloxacin if additional gram negative coverage needed) OR Aztreonam + Levofloxacin + Vancomycin
New Antimicrobial Stewardship Standard. Available at: https://www.jointcommission.org/assets/1/6/new_antimicrobial_stewardship_standard.pdf. Accessed 2016 Jul 25. Basic 7. Hospitals collect, analyze, and report data on its antimicrobial stewardship program Adhere to facilityspecific treatment recommendations Accurately document antibiotic allergy histories Intermediate Sequentially track antibiotic resistance patterns Track 30-day readmission rates for pneumonia and C. difficile At or Better Than Target (within goal) Advanced Track number of antibiotics administered to patients per day (days of therapy) Report grams of antibiotics used (defined daily dose) Area of Concern (within goal, but in danger of not meeting goal next quarter) Not Meeting Target (not at goal) D
New Antimicrobial Stewardship Standard. Available at: https://www.jointcommission.org/assets/1/6/new_antimicrobial_stewardship_standard.pdf. Accessed 2016 Jul 25. 8. Hospitals take action on improvement opportunities identified in its antimicrobial stewardship program D Antibiotic formulary restrictions Automatic alerts for potentially duplicative drug therapy Criteria for Use ID Consult within 24 hours of initiation Ertapenem Fosfomycin Itraconazole Linezolid Micafungin IV Amphotericin B IV Colistin Daptomycin Voriconazole Ordering Restricted to ID Practitioners ONLY Cefepime and Pipercillin/Tazobactam represent a potential duplication in therapy Tigecycline
Resource Toolkit Centers for Disease Control Get Smart About Antibiotics http://www.cdc.gov/getsmart/index.htmlcenters for Medicare and Medicaid Services Centers for Medicare and Medicaid Services Conditions of Participation http://s3.amazonaws.com/public-inspection.federalregister.gove/2016-13925.pdf Infectious Diseases Society Guidelines Developing an Institutional Program to Enhance Antimicrobial Stewardship http://cid.oxfordjournals.org/content/44/2/159.full.pdf+html Prevention of Antimicrobial Resistance in Hospitals http://cid.oxfordjournals.org/content/25/3/584.full.pdf+html National Quality Forum National Quality Partners Playbook www.qualityforum.org/nqp/antibiotic_stewardship_playbook.aspx
Learning Assessment 1. Which of the following is not a required member of the antimicrobial stewardship team? a. Infectious Diseases Physician b. Pharmacist c. Registered Dietitian d. Infection Preventionist New Antimicrobial Stewardship Standard. Available at: https://www.jointcommission.org/assets/1/6/new_antimicrobial_stewardship_standard.pdf. Accessed 2016 Jul 25.
Antibiotics are a shared resource, and becoming a scarce resource. Appropriate Antibiotic Use. Available at: http://www.cdc.gov/getsmart/healthcare/resources/factsheets/pdf/antibiotic-use.pdf. Accessed on 2016 Jul 22.