Antimicrbial Stewardship: Why, What, and Hw David P. Calfee, MD Teresa Lubwski, Pharm.D A partnership f the Healthcare Assciatin f New Yrk State and the Greater New Yrk Hspital Assciatin
Antimicrbial use is very cmmn Acute care hspitals Pint prevalence in 183 US hspitals: 51.9% 63.7% f patients in 70 US academic hspitals Lng-term care facilities Up t 70% f residents receive 1 r mre curses Outpatient settings 266.1 millin curses f antibitics dispensed frm cmmunity pharmacies in 2014 5 prescriptins fr every 6 peple in the US Magill SS. N Engl J Med 2014; 370:1198-1208 Plk RE. Clin Infect Dis 2011;53:1100-10 CDC. 2014. www.cdc.gv/getsmart/cmmunity/pdfs/annual-reprtsummary_2014.pdf
Antimicrbial therapy is assciated with several ptential cmplicatins Allergy Txicity Vascular access-related cmplicatins (infectin, thrmbsis) Alteratin f micrbime C. difficile infectin Antimicrbial resistance Patient-level prblem Scietal prblem
Antimicrbial resistance is a serius public health threat https://www.cdc.gv/drugresistance/threat-reprt-2013/
Antimicrbial resistance is clsely assciated with antimicrbial use Neuhauser MM. JAMA 2003;289:885-8
Antibitic expsure is a majr risk factr fr carriage f and infectin with MDRO Cmparisn Antibitics within 3 mnths Odds Rati P value CRE vs uninfected cntrls 11.4 0.006 CRE vs susceptible Enterbacteriaceae 12.3 <0.001 CRE vs ESBL 5.2 0.015 MDRO: multidrug-resistant rganisms CRE: carbapenem-resistant Enterbacteriaceae ESBL: extended-spectrum β-lactamase-prducing Enterbacteriaceae Marchaim D. Infect Cntrl Hsp Epidemil 2012;33:817-30
Unnecessary and inapprpriate antimicrbial use alters the risk-t-benefit rati
Antimicrbial use is frequently unnecessary r inapprpriate Setting Unnecessary r Inapprpriate Use Acute care hspitals 30-50% Lng-term care facilities 25-75% Outpatient settings 30-50% Unnecessary: An antimicrbial agent is administered r prescribed when there is n indicatin fr antimicrbial therapy (e.g., giving an antibitic in the setting f a viral upper respiratry infectin) Inapprpriate: A prescribed antimicrbial agent is inapprpriate in selectin, dse, r duratin Hecker MT. Arch Intern Med 2003;163:972-8 Shaughnessy MK. Infect Cntrl Hsp Epidemil 2013;34: 109-16 Fleming-Dutra K. JAMA 2016;315:1864-73 CDC. MMWR Mrb Mrtal Wkly Rep 2011;60:1153-6 Shapir DJ. J Antimicrb Chemther 2014;69:234-40
Antimicrbial use is frequently unnecessary r inapprpriate Unnecessary Use Treatment f syndrmes that are nt infectius in nature Administratin f antibacterial agents fr syndrmes caused by viruses Treatment f test results that represent clnizatin r cntaminatin, rather than infectin Inapprpriate Use Use f an agent with a spectrum f activity that is brader than necessary Prescriptin f dses that are either t high r t lw Use f an agent that des nt prvide activity against the bacteria causing disease Administering a curse f antibitic therapy r prphylaxis that is lnger than necessary
There are many reasns fr unnecessary and inapprpriate prescribing Insufficient knwledge and/r training Lack f cnfidence interpreting antibitic susceptibility testing results Lack f awareness f evidence-based guidelines Subptimal diagnstic testing and evaluatin Patient preference/demand Prir experience and anecdtes
Structured prgrams t imprve antimicrbial prescribing can imprve patient utcmes 78% f studies reprted imprvements in micrbial utcmes (i.e., antimicrbial resistance). 74% f studies reprted in imprvements in antimicrbial prescribing (use, selectin, timing, r duratin). 38% f studies that reprted patient utcmes reprted imprvement in at least ne utcme (e.g., mrtality, LOS, readmissin, C. difficile infectin). N studies reprted harms assciated with implementatin f these prgrams. Wagner B. Infect Cntrl Hsp Epidemil 2014;35:1209-28
Antibitic Stewardship- What it is Antibitic Stewardship is defined as, crdinated interventins designed t imprve and measure the apprpriate use f antibitic agents by prmting selectin f the ptimal drug regimen including dsing, duratin f therapy and rute f administratin. IDSA and SHEA Antimicrbial stewardship is a crdinated prgram that prmtes the apprpriate use f antimicrbials (including antibitics), imprves patient utcmes, reduces micrbial resistance, and decreases the spread f infectins caused by multidrug-resistant rganisms. APIC 12
Antibitic Stewardship- What it is The gals f antimicrbial stewardship prgrams include attenuating r reversing antimicrbial resistance, preventing antimicrbial related txicity, and reducing the csts f inapprpriate use and health care assciated infectins. ASHP Antibitic stewardship prgrams are multi-faceted appraches t ptimize antibitic prescribing, encmpassing cmpnents such as plicy, guidelines, surveillance, educatin, epidemilgy f current resistance, and prcess measurement. Successful antibitic stewardship prgrams mnitr and direct antimicrbial use, prviding a standard, evidence-based apprach t judicius antibitic use in a healthcare facility. AMA 13
Antibitic Stewardship Prgram Guidelines- IDSA and SHEA Summary Recmmendatins: Preauthrizatin and r prspective audit and feedback Develpment f facility specific clinical practice guidelines ASP interventins t imprve antibitic use and clinical utcmes that target patients with specific infectius diseases ASP interventins designed t reduce the use f antibitics assciated with a high risk f CDI Use f strategies t encurage prviders t perfrm rutine review f antibitic regimens t imprve prescribing Incrpratin f clinical decisin supprt (CDS) at the time f prescribing int ASP Recmmend the implementatin f PK mnitring and adjustment prgrams fr aminglycsides and vancmycin Advcate fr the use f alternative dsing strategies vs. standard dsing fr brad spectrum B-lactams t decrease cst Recmmend prgrams t increase bth apprpriate use f ral antibitics fr initial therapy and timely transitin f patients frm IV t PO Barlan T.F. et al. Implementing an antibitic stewardship prgram: Guidelines by the infectius disease sciety f America and the sciety fr Healthcare Epidemilgy f America. CID 2016; 62: e51-e77.
Antibitic Stewardship Prgram Guidelines- IDSA and SHEA Summary Recmmendatins: ASPs shuld prmte allergy assessments and penicillin skin testing when apprpriate ASPs shuld implement guidelines and strategies t reduce antibitic therapy t the shrtest effective duratin. Suggest ASPs develp stratified antibigrams ASPs shuld recmmend selective and cascade reprting f antibitics ver reprting f all antibitics Suggest the use f rapid viral testing fr respiratry pathgens Suggest rapid diagnstic testing in additin t cnventinal culture and rutine reprting n bld specimens if cmbined with active ASP supprt and interpretatin. Suggest the use f serial PCT measurements in adults in ICUs t decrease antibitic use Suggest mnitring antibitic use as Days f Therapy in preference t Defined Daily Dse Measure antibitic csts based n prescriptins r administratin instead f purchasing data
CDC CORE ELEMENTS OF ANTIBIOTIC STEWARDSHIP Hspital (2014) Lng Term Care (2015) Outpatient (2016) Leadership Cmmitment Leadership Supprt Cmmitment Accuntability Accuntability Actin Drug Expertise Drug Expertise Tracking and Reprting Actin Actins t Imprve Use Educatin and Expertise Tracking- Mnitring Antibitic Prescribing and Resistance Patterns Reprting-Regular reprting f infrmatin n antibitic use and resistance t dctrs, nurses and relevant staff Educatin Tracking-Mnitring Antibitic Prescribing, Resistance, Use Reprting Infrmatin t Staff n Imprving Antibitic Use and Resistance Educatin
Jint Cmmissin- New Antimicrbial Stewardship Standard Medicatin Management Standard- MM.09.01.01 The rganizatin has an antimicrbial stewardship prgram based n current scientific literature. Effective January 1, 2017 Standard fr Hspitals, Critical Access Hspitals, and Nursing Care Centers CDC cre elements are included in stewardship prgram The Jint Cmmissin. R3 Supplemental Reprt January 2017
Jint Cmmissin- New Antimicrbial Stewardship Standard- Sample Perfrmance Element The hspital's antimicrbial stewardship prgram uses rganizatinapprved multidisciplinary prtcls (fr example, plicies and prcedures). Nte: Examples f prtcls are as fllws: - Antibitic Frmulary Restrictins - Assessment f Apprpriateness f Antibitics fr Cmmunity-Acquired Pneumnia - Assessment f Apprpriateness f Antibitics fr Skin and Sft Tissue infectins - Assessment f Apprpriateness f Antibitics fr Urinary Tract Infectins - Care f the Patient with Clstridium difficile (c.-diff) - Guidelines fr Antimicrbial Use in Adults - Guidelines fr Antimicrbial Use in Pediatrics - Plan fr Parenteral t Oral Antibitic Cnversin - Preauthrizatin Requirements fr Specific Antimicrbials - Use f Prphylactic Antibitics Reference: The Jint Cmmissin. R3 Supplemental Reprt January 2017