Ready to Launch: Antimicrobial Stewardship for All! Lucas Schulz, PharmD, BCPS AQ ID Clinical Coordinator Infectious Diseases PGY2 Infectious Diseases Residency Program Director Disclosures Consultant for Merck Health and Healthcare Solutions ILUM Conflicts were resolved through peer review Objectives Explain the need for antimicrobial stewardship in today's healthcare environment. Name organisms that have been identified as particularly concerning to public health. List strategies to achieve the CDC core elements and address resistant organisms. 1
Why do we need antimicrobial stewardship? What is Antimicrobial Stewardship? Antimicrobials are social drugs and need everyone to use appropriately Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug resistant organisms. Association for Professionals in Infection Control and Epidemiology Why is it important? GAO report: antimicrobial resistance 2011 2
Name organisms that have been identified as most concerning to public health by the CDC 1. Clostridium difficile, carbapenem resistant Enterobacteriaceae (CRE) and drug resistant Neisseria gonorrhoeae 2. Vancomycin resistant Enterococcus (VRE), penicillin resistant Streptococcus pneumoniae, Clostridium difficile 3. Methicillin resistant Staphylococcus aureus (MRSA), CRE, and VRE Background 2 million people annually in the U.S. acquire serious infections from bacteria with resistance to 1 or more drugs 23,000 of these people die each year Estimates of $20 billion are spent in excess direct healthcare costs each year due to antibiotic resistance CDC Antibiotic Resistance Threats in the United States, 2013 8 Emerging Threats Urgent C. difficile Carbapenem resistant Enterobacteriaceae Drug resistant Neisseria gonorrhoeae Serious MDR Acinteobacter, Pseudomonas, Salmonella, Shigella, tuberculosis ESBLs MRSA Drug resistant Strep Pneumo Concerning Vancomycin resistant Staphylococcus aureus Erythromycin resistant Streptococcus Group A Clindamycin resistant Streptococcus Group B 9 CDC Antibiotic Resistance Threats in the United States, 2013 3
What can health care practitioners do? Improved testing to promote rapid detection and isolation of patients Infection control policies re: cleaning and hand washing Prescribe antibiotics wisely Wash hands with soap and water CDC Antibiotic Resistance Threats in the United States, 2013 10 Is this a real threat? Resistant to nearly ALL antibiotics CDC has confirmed CRE in 44 states (including WI) Most infections in the urine Bloodstream infections have 50% mortality CDC Antibiotic Resistance Threats in the United States, 2013 11 Carbapenem Resistant Enterobacteriaceae What can health care practitioners do Know regional microbiology Service/Unit specific antibiograms Caution in interpreting national databases Notification of patient transfer Improve microbiology lab identification Prescribe antibiotics wisely This is the reason for antimicrobial restrictions 12 4
Gonorrhea is 2 nd most commonly reported notifiable infection in the US 25% of infections per year are with drug resistant strains! If cephalosporin resistance becomes wide spread, this will result in ~75,000 new PID cases per year, 15,000 cases of epidiymitis, and 222 HIV cases CDC Antibiotic Resistance Threats in the United States, 2013 13 Role for information technology to predict/identify resistance patterns early 14 CDC Antibiotic Resistance Threats in the United States, 2013 15 5
Why is antimicrobial stewardship important? Photos from cnnmoney.com and GAO report: antimicrobial resistance 2011 Financial impact of stewardship 106 patients accounting for 47.8% of the budget ($1,886,599) Top 1% Budget Busters 50.00% $70,000 % of Total Antimicrobial Cost 45.00% 40.00% 35.00% 30.00% 25.00% 20.00% 15.00% 10.00% 5.00% $60,000 $50,000 $40,000 $30,000 $20,000 $10,000 Antimicrobial Cost per Patient 0.00% $0 1 5 9 13 17 21 25 29 33 37 41 45 49 53 57 61 65 69 73 77 81 85 89 93 97101105 Patient (n) Who has stewardship programs? What constitutes a stewardship program? Comprehensive stewardship? 6
7 Core Elements of Hospital Stewardship Leadership Commitment Accountability Drug Expertise Action Tracking Reporting Education http://www.cdc.gov/getsmart/healthcare/implementation/core elements.html 19 Established 2001 0.5 FTE MD, 0.5 FTE Pharmacy Antimicrobial Stewardship Program 2010 Add 1.0 FTE PGY2 ID resident 2016 Add 0.2 FTE Pediatric MD 1.0 FTE PharmD 2008 Add 0.5 FTE Pharmacy 2011 Add 0.5 FTE MD 1.2 FTE ID trained Physician 2.0 FTE ID trained Pharmacist PURPOSE: To provide a collaborative, interdisciplinary system for the optimization of antimicrobial use within the University of Wisconsin Hospital and Clinics to improve drug selection, slow the emergence of antimicrobial resistance, reduce antimicrobial expenditures, and improve patient outcomes. Stewardship Stakeholders: Hospitalist, Surgeon, Microbiology, Infection Control, Information Technology, Clinical Pharmacists, Infectious Diseases Physicians 1.0 FTE PGY2 Infectious Diseases Pharmacy Resident 20 Leadership Commitment, Accountability, Drug Expertise Continued support of hospital leadership Recent expansion for Pediatric, Outpatient, Outreach stewardship activities Adoption/Implementation the Epic ICON module Chief, Division of Infectious Diseases David Andes, MD Antimicrobial Stewardship Medical Directors Barry Fox, MD and Alex Lepak, MD Pediatric Antimicrobial Stewardship Director Sheryl Henderson, MD, PhD Infectious Diseases Clinical Coordinator Lucas Schulz, PharmD, BCPS AQ ID Infectious Diseases Clinical Pharmacist Tyler Liebenstein, PharmD, BCPS 21 7
Action Systematic evaluation of antibiotics Post prescriptive audit/review all antimicrobials, all patients every day, every hospital ~300 patients per day Low hanging fruit to clinical pharmacists Focus on de escalation and duration discuss cases with ID physician Minimally invasive intervention mechanism Restrictive antimicrobial drug monitoring 16 hours per day 27 restricted antimicrobials 0700 2300 coverage by ID physician or ID fellow 22 Post-prescriptive Audit and Review 23 2017 Epic Systems Corporation. Used with permission. 2017 Epic Systems Corporation. Used with permission. 24 8
2017 Epic Systems Corporation. Used with permission. 25 2017 Epic Systems Corporation. Used with permission. 26 Minimally Invasive Interventions 2017 Epic Systems Corporation. Used with permission. 20 templates for intervention progress notes. Negative cultures Cultures needed Duplicate coverage Nearing completion De escalation No risk for resistance Susceptibility mismatch Restricted drug use PK/PD dose adjustment IV >PO adjustment Drug interaction alert 27 9
Tracking Prescribing and Resistance Patterns Data integrity is key! Easy data dose, route, prescriber, unit Hard data INDICATIONS! 2017 Epic Systems Corporation. Used with permission. 28 Tracking Prescribing and Resistance Patterns % of inpatient admissions receiving FQ for Jan 2015 through Jan 2016 18.0% 1.5 Percent of inpatient admissions receiving FQ 16.0% 14.0% 12.0% 10.0% 8.0% 6.0% 4.0% 2.0% 0.0% 1.4 1.3 1.2 1.1 1 0.9 0.8 0.7 5.7% 6.1% 6.3% 7.0% 7.1% 8.3% 8.8% 9.3% 10.0% 10.3% 10.5% 11.7% 11.9% 12.0% 12.0% 12.2% 12.4% 13.3% 13.8% 13.9% 14.3% 16.9% 0.6 TLC indications B4/6 Indications Clostridium difficile infection Standardized Infection Ratio Other 11% UTI 11% Bloodstream 15% Abdominal/ Pelvic 20% Lower RTI 43% Other 10% UTI 27% Transplanted Organ 7% Bloodstream 6% Lower RTI 18% Abdominal/ Pelvic 32% 29 Fluoroquinolone use and HA CDI cases Days of Therapy per 1000 Patient Days Antibiotic Utilization 180 160 140 120 100 80 60 40 20 Number of HA CDI cases Transplant Critical Care Antimicrobial Utilization Transplant Critical Care Intervention Start Date 5 4 4 3 3 2 2 1 1 Number of Hospital acquired Clostridium difficile Infections 0 0 Jun 2015 Jul 2015 Aug 2015 Sep 2015 Oct 2015 Nov 2015 Dec 2015 Jan 2016 Feb 2016 Mar 2016 Apr 2016 May 2016 Jun 2016 Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 HA CDI case rate (cases/10000 PD) Pre intervention Post intervention University Hospital p=0.05 8.36 5.65 Pilot Units p=0.12 16.8 7.7 30 10
Reporting to administration Focus on patient improvement projects in annual report 85% acceptance rate of interventions Fiscal reports summarized as cost per admission and % of total inpatient drug cost 31 Keys to Successful Stewardship Engage anyone and everyone you can! Decentralize stewardship! Focus on systems and processes! Share your programs successes! Engage Everyone! Nurses Patient education Question antibiotic route Participate in 48 72 hour antimicrobial timeout Critically assess need for lab testing (i.e. Clostridium difficile) Medication reconciliation Laboratory Test only if clinical presentation is consistent with infectious etiology Optimize sample collection and transport (i.e. blood culture policies) Rapid diagnostics (i.e. PNA FISH, MALDI TOF, PCR based testing) Providers Engage local ID experts Clinical guidelines, delegation protocols Report back to all on successes! Administration The Joint Commission standard Annual Report Gillespie E, Rodrigues A, Wright L, Williams N, Stuart RL. Improving antibiotic stewardship by involving nurses. Am J Infect Control. 2013;41(4):365 7. Morgan D, Malani P, Diekema D. Diagnostic stewardship leveraging the laboratory to improve antimicrobial use. JAMA. 2017; epub July 31, 2017 11
What strategies could you apply at your institution to achieve at least 1 of the CDC core elements? The Joint Commission Antimicrobial Stewardship Standard Elements of Performance Leaders establish stewardship as organizational priority Hospital educates staff and practitioners upon hire and periodically thereafter Hospital educates patients and families regarding appropriate use of antimicrobials Antimicrobial stewardship composed of multidisciplinary team Antimicrobial stewardship meets CDC s 7 core elements Organizational multidisciplinary protocols are in use Program collects, analyzes, and reports data Takes action identified by the antimicrobial stewardship program Ready to Launch: Antimicrobial Stewardship for All! Lucas Schulz, PharmD, BCPS AQ ID Clinical Coordinator Infectious Diseases PGY2 Infectious Diseases Residency Program Director lschulz2@uwhealth.org 12
Panel Discussion Alan Gross, Pharm.D., BCPS AQ ID Margaret Heger, Pharm.D., BCPS, BCPPS Jennifer Pisano, M.D. Radhika Polisetty, Pharm.D., BCPS AQ ID, AAHIVP Panelists have no conflicts of interest to disclose Questions? 13