How to Organize an Antimicrobial Stewardship Team in a Hospital Bojana Beović University Medical Centre Ljubljana Faculty of Medicine, University of Ljubljana, Slovenia
Antibiotic Stewardship: The Definition Antimicrobial stewardship encompasses a wide range of processes and interventions that are designed to ensure that antibiotics are used in the most effective manner. The goals of antibiotic stewardship can be summarised in optimising therapy for individual patients; preventing overuse and misuse; and minimising the development of resistance at patient and community level. www.gov.uk/government/uploads/system/uploads/attachment_data/file/405031/behaviour_change_for_antibiotic_prescribing_-_final.pdf
Antibiotic Stewardship: The Definition Antimicrobial stewardship encompasses a wide range of processes and interventions that are designed to ensure that antibiotics are used in the most effective manner. The goals of antibiotic stewardship can be summarised in optimising therapy for individual patients; preventing overuse and misuse; and minimising the development of resistance at patient and community level. www.gov.uk/government/uploads/system/uploads/attachment_data/file/405031/behaviour_change_for_antibiotic_prescribing_-_final.pdf
Antimicrobial Stewardship Interventions Recommended by IDSA/SHEA 2016 preauthorization and/or prospective audit and feedback education local guidelines treatment of specific syndromes limiting the use of antibiotics associated with Clostridium difficile diarrhea TDM, PK/PD dosing optimisation of switch to oral and duration of treatment implementation of computerized prescribing.
http://tacticsdigital.com/taking-the-virtual-out-of-working-with-a-virtual-assistant/
Multidisciplinary team: AIII Multidisciplinary team: A
Interventions to improve antibiotic prescribing practices for hospital inpatients (review) Davey P, Brown E, Fenelon L, et al. Cochrane Database of Systematic Reviews 2005; Issue 4. Art.No CD003543. - Publications 1966 to Nov 2003 - Publications from 1980 to the end of 2006
Deliverer of the Intervention 40 35 30 25 20 15 10 5 0 1966 to 2003 1980 to 2006 60% 50% 40% Other: primary team, policy change, computers. Davey P, et al. 2005 and 2013 30% 20% 10% 0% multidisciplinary team before 2003 after 2003
The Role of the Team decrease in mortality reduction in nosocomial infections shorter length of hospital stay improved quality of prescribing fewer drug-related adverse events Gums JG, et al. Pharmacother 1999; 19:1369-77. Solomon DH, et al. Arch Intern Med. 2001;161:1897 902. Carling P, et al. Infect Control Hosp Epidemiol 2003;24:699 706. 30. Bantar C, et al. Int J Infect Dis 2006;10:231 5. 31. Bevilacqua S, et al. Int J Clin Pharm 2011;33:521 8. 32. Danaher PJ, 33. Diamantis S, Med Mal Infect 2010;40:637 43 (II). 34. Gendrin V, et al. Presse Med. 2012;41:e10 4. 35. Bauer S, et al. Med Mal Infect. 2012;42:603 7.
Multidisciplinary team: Infectious disease physician Pharmacist with antimicrobial stewardship training Compensated for their time Clinical microbiologist Information system specialist Infection control professional Hospital epidemiologist Recommendation AIII
Infectious diseases physician (or clinician with infectious diseases training) experienced clinical pharmacist/hospital pharmacist specialist in microbiology, virology and infection epidemiology physician locally responsible for infection control.
The Leading Role of ID Physician in Multidisciplinary Antimicrobial Stewardship Team (MAST) increased acceptance and compliance of the program by other physicians reduced perception that a stewardship program is a pharmacydriven cost-saving scheme Dellit TH, et al. Clin Infect Dis 2007; Tamma PD, Cosgrove SE. Infect Dis Clin N Am 2011; 25: 245 260.
The Impact of Infectious Diseases Specialist Consultations More appropriate empirical and targeted treatment Adjustment of treatment Less complications Lower mortality Shorter LOS Shorter mechanical ventilation Earlier discountinuation of treatment More frequent switch to oral Less cost (ambiguous results of some studies) Uckay I, et al. J Infect 2009, Borer A, et al. Clin Microbiol Infect 2004; 10:911-16., Rainieri E, et al. Am J Infect Control 2008; 36: 283-90., Honda H, et al. Am J Med 2010; 123:631-7., Fluckiger U, et al. EJCMID 2000; 19:493-500., Byl B, et al. Clin Infect Dis 1999; 29: 60-6. Classen DC, et al. Clin Infect Dos 1997; 24:468-70.
IDP and Antibiotic Stewardship Programmes: 1993 Clin Infect Dis 1997; 24: 468-79. Cases with IDP consultation had longer lengths of hospital stays, longer intensive care unit lengths of stays, and higher antibiotic costs than did matched controls. Consultation in the last one-third: shorter length of stay and lower cost
101,991 hospital stays with and 170,336 without ID consultation Adjustment analysis showed that ID interventions were done in more severely ill patients Significantly lower mortaliy and readmission rate with ID intervention If intervention was performed within 2 days of admission, the patients had significantly lower mortality, re-admission rate, hospital and ICU stay, and cost of treatment
http://uems-id.eu/index.php/training
Compliance to Recommendations: does experience matter? Recommendations were followed less often when given by the 1 st year trainees than older trainees (69.7 vs 78.5%, p=0.02, but non-significant with the logistic regression analysis) Sipahi OP, et al. Int J Infect Dis 2007; 11: 518-23. Compliance to the advice of board-certified IDP was higher than to the advice of a trainee (89 vs 74%, p=0.02) Gennai S, et al. Med Mal Infect 2009; 39: 798-805. Decrease in compliance to the advice and increase in broad-spectrum antibiotic prescribing after the replacement of senior doctors by trainees. Yeo CL, et al. Antimicrob Res Infect Control 2012, 1:36. Compliance to the advice is related to the year since the fellowhsip of the deliverer: < 6 years: 81% 6-10 years: 89% > 10 years: 77% Lo E, et al. Clin Infect Dis 2004; 38: 1212-8.
How Far to Go: just an advice or total control? (DDD/100 patient-days) A, restricted antibiotics under ID control, B, restricted antibiotics approved by head of the department, C, total ID control 1,2 1 NS A B C 0,8 NS 0,6 0,4 P=0.006 0,2 0 1998 1999 2000 2001 2002 2003 2004 2005 Beović B, Čižman M, Seme K, Kreft S. J Chemother 2009; 21:46-61.
Responsibility? The AS team member? The primary team? Shared responsibility?
Bed-side consultations are more effective than telephone in patients with S. aureus bacteremia 342 episodes of S. aureus bacteremia, 72% bedside consultations Less ICU admissions (OR 0.35) More deep foci of infection identified (OR 3.11) Lower mortality rate (7-days: OR 0.09, 28-days: OR 0.27, 90-days: OR 0.25) Deleterious effect of telephone consultation on 90-days mortality (OR 2.31 in comparison with bed-side consultation) in multivariate analysis Forsblom E, et al. Clin Infect Dis 2013;56:527 35.
Bedside consultations found as one of 6 successful interventions in antimicrobial stewardship. Lancet Infect Dis 2016;16:847-56.
If there are no ID physicians in the hospital: ABS officer: at least one trained physician who dedicates a portion of his/her time to the design, implementation and function of the program
The Pharmacists in Antimicrobial Switch to oral Stewardship Better adherence to guidelines Shorter duration of therapy Reduced cost Dose adjustment to impaired organ function Weber A, et al. Zenttalbl Chir 2011; 136:66-73., McLaughlin CM, et al. QJM 2005; 98:745-52., Toth NR, et al. Am J Health Syst Pharm 2010; 67:746-9., Dunn K, et al. Int J Clin Pharm 2011; 33:208-14., Bailey TV, et al. Pharmacotherapy 1997; 17:277-81., Dranitsaris G, et al. Int J Technol Assess Health Care 2001; 17:171-80.
Education of pharmacists in antimicrobial stewardship and prescribing UK: Clinical Pharmacy Association Pharmacy Infection Network has developed a professional curriculum for antimicrobial pharmacists. USA: several educational programmes for ID pharmacists which include some aspects of antibiotic stewardship. Scottish Doctors Online Training System (DOTS). Chahine AB, et al. Journal of Pharmacy Practice 2015; 28: 585-91. Nathwani D, et al. J Antimicrob Chemother 2011; 70: 1277-80.
The expertise of the medical microbiologist to establish local guidelines for laboratory diagnostics of infection including pre-analytical specimen management to report microbiological results in accordance with national and international quality standards accessible current surveillance data on pathogens use of targeted diagnostic tests, rapid reporting and professional communication of results Antimicrobial consultations on the wards De With K, et al. Infection 2016DOI 10.1007/s15010-016-0885-z Kathari A, et al. EJCMID 2008;14:1187-8. O Neill E, et al. Clin Infect Dis 2005; 40:636-7.
ID or CM for antimicrobial stewardship on ward level Clin Microbiol Infect 2005; 11 (Suppl. 1): 28 32
- unrecognized - underestimated - centrally positioned at bedside - 24/7 Clin Infect Dis 2016; 62:84-9.
Nurses in Antimicrobial Stewardship: the Educational Needs Olans RD, et al. J Contin Nurs Educ 2015; 46: 318-21.
How Many Physicians for an AS Team in a Hospital?
Staffing for infectious diseases, clinical microbiology and infection control in hospitals in 2015: results of an ESCMID member survey The median ID/CM/IC physician per 100 hospital beds ratio was 1.12 (interquartile range 0.56-2.13) In hospitals performing basic ASP and IC (including local antibiotic guidelines and monitoring device related or surgical site infections), the ratio was 1.21 (interquartile range 0.57-2.14). In hospitals performing regular ASP and IC activities, including the publication of local antibiotic guidelines and monitoring device-related or surgical site infection without a specialized ID ward or dedicated beds for IDs the the median was 0.68 (IQR 0.36-1.39) physicians per 100 hospital beds. Dickstein Y, et al. Clin Microbiol Infect. 2016 Sep;22(9):812.e9-812.e17
Based on several studies analysing the impact of the AS interventions in the hospitals: 0.5 and 1.5 fulltime equivalent posts depending on the number of beds (~200 to ~900) or level of care provided, equating to one full-time equivalent of 0.5 per 250 300 beds.
Human Resources Needed to Perform Antimicrobial Stewardship Teams' Activities in French Hospitals The human resources needed to implement all AST's activities were estimated at - 3.6 full-time equivalent (FTE) positions/1000 acute care beds for antibiotic/infectious disease lead supervisors - 2.5 FTE/1000 beds for pharmacists - 0.6 FTE/1000 beds for microbiologists Med Mal Infect 2016;46(4):200-6.
The Committee
2166 hospital beds 115,599 admissions Average length of stay: 5.64 days 7884 employees 1212 medical doctors Antibiotic Committee since 1976 Members: ID, CM, IC, pharmacy Surgery, medicine, hematology, ICU, ENT, ophtalmology, pediatrics, gynecology, dermatology, neurology The Committee meets 2/ year The Committee discuss the antimicrobial consumption and resistance data and makes decisions about hospital-wide interventions
Conclusions Set up a Committee Roll out a team The team members must be compensated (not an add-on activity!) Keep AS as bed-side activity Invest in education of team members Never give up
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