Antimicrbial Stewardship Team - Pilt Prpsal Summary In 2005, the adult ppulatin in the XXX Hspital accunted fr 80% f the anti-infective budget. Fifteen f the tp 20 anti-infective budget items were ID restricted agents. Currently, ID fellws prvide apprximately 11,000 restricted antibitic apprvals annually, f which 9000 apprvals are granted fr the adult ppulatin. A well-staffed antimicrbial stewardship team at XXX can be a valuable asset, as antibitic use, antibitic resistance, and infectin cntrl g hand in hand. A cmprehensive apprach t antibitic use beynd an apprval system relies heavily n Clinical Pharmacy (PharmD) participatin t prvide apprvals, fllw up n all patients receiving antibitics thrughut the institutin, prvide pharmackinetics dsing services, and perfrm targeted surveillance. Additinal PharmD staffing can help this prgram achieve its gals: Decrease antibitic csts Stabilize antibitic resistance Imprve patient safety Reduce burden n ID fellws and thereby imprve their clinical training FTEs fr 2 additinal infectius diseases-trained clinical pharmacists are requested. The activities described belw wuld be gradually phased in ver the next 2 years. Backgrund Antibitic resistance is a significant and prgressively wrsening prblem at healthcare facilities arund the wrld. This fact, cmbined with the lack f new antimicrbial agents in the drug develpment pipeline, indicates that judicius antimicrbial management is necessary t preserve the antibitics currently available. Adverse utcmes result frm inapprpriate chice, dse, frmulatin, r duratin f antibitics and include increased cst and antibitic resistance, alng with increased mrbidity, mrtality, and length f stay. Increased csts assciated with antibitic use are derived frm numerus factrs, including direct antibitic drug expenditures and hspital and/r intensive care unit length f stay. Stabilizing antibitic resistance requires a multiprnged apprach including frmulary restrictins, educatin and guidelines, review and feedback, and clse surveillance f antibitic utilizatin and resistance patterns, with interventins made n a daily basis t ptimize antibitic therapy. Recent literature demnstrates that these activities are mst successful with the implementatin f multidisciplinary antibitic stewardship teams invlving infectius diseases physicians and infectius diseases-trained clinical pharmacists: Carling et al (1999) 1 Cmparisn f 14 hspitals shwed that nly a prspective multidisciplinary interventin prgram was crrelated with a decrease in antibitic cst. Bantar et al (2003) 2 Multidisciplinary antimicrbial treatment cmmittee led t decreased antibitic csts (savings >$900,000) and decrease in certain types f antibitic resistance. Gums et al (1999) 3 Multidisciplinary team led t a decrease in length f stay (by 3.3 days) and in median hspital csts ($2642 per interventin). Finally, adult ID fellws currently prvide apprximately 9000 apprvals annually, amunting t abut 25 apprvals each day. These numbers estimate actual apprvals and d nt reflect rejected requests and phne cnsultatins, which significantly inflate the number f phne calls managed daily. This number has subjectively increased in recent years alng with the acuity f the patient ppulatin. The need t balance the apprval system with fellws educatinal needs accrding t GME requirements places at least ne f these prcesses at a disadvantage n a daily basis. Decreasing the number f hurs during which ID fellws are
respnsible fr antibitic apprvals wuld allw them t participate mre fully in attending runds and spend mre time n their cnsultative activities. Current pharmacy staffing levels are limited t direct patient care activities with the ID Cnsult services and are insufficient t meet the needs f a cmprehensive prgram as utlined in this prpsal. A cmprehensive prgram can imprve patient safety, stabilize r decrease antibitic resistance, and prvide significant cst savings via the fllwing interventin pprtunities: Prpsed Activities 1. Antibitic apprvals Antibitic apprvals have traditinally been managed by infectius disease fellws at many academic institutins, including XXX. Currently, the adult ID fellws prvide apprximately 9000 apprvals annually (750 apprvals each mnth). Hwever, as this is nly ne aspect f their training, fellws frequently are limited in time and incentive t carefully cnsider and respnd t each request. In additin, their time cnstraints limit their ability t be cmpletely familiar with all relevant epidemilgy within the hspital that wuld guide antibitic decisins. Under the directin f Dr. Neil Fishman, the Hspital f the University f Pennsylvania develped a multidisciplinary antibitic management team with clinical pharmacists prviding antibitic apprvals. This prgram has shwn that the clinical pharmacists utperfrmed the infectius diseases fellws n all measures, including apprpriateness f antibitic suggestins and cure rate. 4 The prgram was als fund t be cst-effective, demnstrating annual savings f $300,000 fr antibitic csts, $500,000 fr infectin-related csts, and >4.25 millin in ttal csts. 5 2. Pst-prescribing review/fllw-ups The antibitic restrictin and apprval prcess is imprtant in reducing the inapprpriate use f antibitics. Hwever, currently this prcess nly affects the initial chice f antibitic therapy. Pst-prescribing review can be imprtant in many ways, including tailring antibitics t subsequent micrbilgy results, changing antibitics frm brad t narrwer-spectrum (deescalatin), shrtening duratin f antibitic therapy, adjusting antibitic dses based n drug levels and end-rgan functin, and cnverting an antibitic frm an intravenus t ral frmulatin. IV t PO cnversins Pharmacists can review the utilizatin f select newer intravenus antibitics with excellent ral biavailability (e.g. linezlid and vricnazle) that have nt previusly been mnitred due t resurce cnstraints. This wuld be an enhancement t ur current activities. This includes selected new intravenus agents. This can result in significant cst savings as ral frmulatins are frequently less cstly than intravenus preparatins and equally effective if utilized in the apprpriate patient ppulatins. Antibitic duratin >7 days Duratin f antibitic therapy in the hspital setting is ften lnger than necessary based n a perceived benefit f lnger duratins despite clinical imprvement early in the curse f therapy. 6 Lnger duratins tend t prmte superinfectin with rganisms that are mre resistant. Pharmacists can review all patients wh are receiving antibitics fr at least 7 days t assess the pssibility fr discntinuatin. Shrtening duratin f therapy where feasible can decrease antibitic drug csts. Vancmycin and carbapenem duratin >3 days Vancmycin and carbapenems are antibitics where there is particular cncern regarding veruse. Empiric therapy with these agents in severely ill patients is ften reasnable initially but can be subsequently discntinued when mre micrbilgical data is available shuld mre susceptible rganisms be identified.
As abve, pharmacists can review these cases and recmmend discntinuatin where feasible. Brad spectrum antibitic use can be limited and drug csts decreased by this prcess. Duplicate therapy Patients may unnecessarily receive multiple antibitics that cver the same rganisms. Fr instance, a patient may be treated with piperacillin/tazbactam + metrnidazle fr an intra-abdminal infectin where the metrnidazle is added fr a perceived benefit against anaerbic rganisms. Treatment with bth f these agents is nt necessary. Similarly, linezlid may be added t vancmycin therapy t cver vancmycin-resistant gram-psitive rganisms where the linezlid alne is sufficient in mst cases. Pharmacists can review these cases and suggest the discntinuatin f ne f the duplicate antibitics. Pharmackinetics service Antibitics such as vancmycin and aminglycsides are challenging t dse and require adjustment based n kidney functin, weight, and age. Diligence in therapeutic drug mnitring f aminglycsides is especially imprtant t avid txicity and maximize efficacy due t their narrw therapeutic index. Despite maximal educatinal effrts, therapeutic level mnitring is ften perfrmed incrrectly, with levels sent at the wrng time during therapy r relative t drug administratin times. Unnecessary csts may accrue due t an increased number f drug levels rdered and ptentially increased hspital length f stay due t ver- r under-dsing with the antibitics. Pharmacists are specifically trained in therapeutic drug mnitring and can fllw patients receiving aminglycsides and vancmycin t ptimize drug dsing based n the efficient use f drug levels. This can result in mre rapid attainment f the crrect dse, thus decreasing the number f serum drug levels sent, maximizing the chance f cure, and minimizing the risk f drug txicity. De-escalatin therapy/streamlining In additin t the abve interventins, there are numerus ther pprtunities fr pharmacists t assist in the de-escalatin and streamlining f antibitic therapy. The develpment f sphisticated cmputerized surveillance systems can aid in the identificatin f patients n inapprpriately brad r narrw therapy. Fr example, cmputerized alerts are being develped at XXX t identify patients whse antibitic therapy des nt match the reprted micrbilgic susceptibilities f the patients rganisms ( bug-drug mismatch alert ). Pharmacists wuld identify patients as described abve and suggest a switch t mre apprpriate antibitic therapy. 3. Surveillance f antibitic utilizatin and resistance patterns Optimal antibitic utilizatin is dependent n a cmplete and up-t-date understanding f the rganisms and resistant patterns that are prevalent in each unit f the hspital. Quarterly surveillance Pharmacists can assist in cmpiling quarterly data n antibitics utilized in each unit and the mst prevalent rganisms in thse units, alng with their susceptibility patterns. Based n these data, the antibitic management team can prvide feedback t each unit with targeted recmmendatins fr antibitic utilizatin. Targeted surveillance Pharmacists can als perfrm targeted usage evaluatins t identify inapprpriate use, pprtunities fr educatin, and the need t ptimize antibitic chices r mnitring. This can be helpful when a ptential prblem in antibitic resistance r antibitic utilizatin in the hspital is recgnized (e.g. increase in Acinetbacter infectins and relatinship t veruse f imipenem, etc.).
Outcme Measurements The success f this prpsal depends n the regular mnitring and evaluatin f the utcmes f interest, namely the impact f these activities n antibitic use, antibitic resistance, and cst savings. An annual reprt will be prvided summarizing these utcme measurements. Interventin Ptential Cst Savings Clinical and Micrbilgic Outcmes Antibitic Apprvals Imprved apprpriateness f antibitic suggestins 5 Pst-prescribing Review IV t PO Cnversins Decrease Antibitic Duratin Duplicate Therapy Pharmackinetics De-escalatin/ Streamlining Surveillance f Antibitic Resistance and Utilizatin $ 103,000 $ 242,000 Imprved infectin cure rate 5 Decrease in antibiticrelated adverse drug events Decrease in median length f stay by up t 3 days 5,7,8 Decrease in antibitic resistance 2,9,10 Decrease in inapprpriate antibitic utilizatin Decrease in antibitic resistance Ttal ptential measurable cst $ 345,000 * savings 2 Additinal FTE s (ID Clinical $ 180,000 ** Pharmacy Specialists) NET POTENTIAL MEASURABLE $ 165,000 COST SAVINGS * additinal cst savings can be achieved by LOS reductins, safety, resistance, and patient utcmes ver time ** excludes benefits
References 1. Carling, P.C., Fung, T. & Cldirn, J.S. Parenteral antibitic use in acute-care hspitals: A standardized analysis f furteen institutins. Clin Infect Dis 29, 1189-96 (1999). 2. Bantar, C. et al. A hspital wide interventin prgram t ptimize the quality f antibitic use: impact n prescribing practice, antibitic cnsumptin, cst savings, and bacterial resistance. Clin Infect Dis 37, 180-6 (2003). 3. Gums, J.G., Yancey, R.W., Jr., Hamiltn, C.A. & Kubilis, P.S. A randmized, prspective study measuring utcmes after antibitic therapy interventin by a multidisciplinary cnsult team. Pharmactherapy 19, 1369-77 (1999). 4. Grss, R. et al. Impact f a hspital-based antimicrbial management prgram n clinical and ecnmic utcmes. Clin Infect Dis 33, 289-95 (2001). 5. Fishman, N. Antimicrbial stewardship. Am J Infect Cntrl 34, S55-63; discussin S64-73 (2006). 6. File, T.M., Jr. Clinical efficacy f newer agents in shrt-duratin therapy fr cmmunity-acquired pneumnia. Clin Infect Dis 39 Suppl 3, S159-64 (2004). 7. Fraser, G.L. et al. Antibitic ptimizatin. An evaluatin f patient safety and ecnmic utcmes. Arch Intern Med 157, 1689-94 (1997). 8. Gentry, C.A., Greenfield, R.A., Slater, L.N., Wack, M. & Huycke, M.M. Outcmes f an antimicrbial cntrl prgram in a teaching hspital. Am J Health Syst Pharm 57, 268-74 (2000). 9. Carling, P., Fung, T., Killin, A., Terrin, N. & Barza, M. Favrable impact f a multidisciplinary antibitic management prgram cnducted during 7 years. Infect Cntrl Hsp Epidemil 24, 699-706 (2003). 10. Mdjtabai, K., Prat, B.S., Stgsdill, P.B. & Owens, R.C.J. Impact f inpatient prescribing changes n antimicrbial susceptibilities: a five-year lngitudinal study [abstr]. in Prgrams and abstracts f the 41st annual meeting f the Infectius Diseases Sciety f America (Alexandria, VA, 2003).