Antimicrobial Stewardship: Setting minimum expectations for optimizing antimicrobial use and addressing resistance Loria Pollack, MD, MPH Centers for Disease Control and Prevention Division of Healthcare Quality Promotion Prevention and Response Branch National Center for Emerging and Zoonotic Infectious Diseases Division of Healthcare Quality Promotion
Overview Outline key elements of antimicrobial stewardship for acute care facilities Present a set of proposed indicators Solicit HICPAC feedback
Background Call for antimicrobial stewardship is repeatedly stated in recent CDC reports Four Core Actions to Prevent Antibiotic Resistance 1. Preventing Infections, Preventing Spread of Resistance 2. Tracking Resistance Patterns 3. Antibiotic Stewardship: Improving Prescribing and Use 4. Developing New Antibiotics and Diagnostic Tests Health care providers can Protect your patients from CRE Prescribe antibiotics wisely CDC Threat Report, 2013 http://www.cdc.gov/drugresistance/threat-report-2013/ CDC CRE Vital Signs, March 2013 http://www.cdc.gov/vitalsigns/hai/cre/
Successful CDC Checklist Available at: http://www.cdc.gov/hai/pdfs/guidelines/standatds-of-ambulatory-care-7-2011.pdf
Transatlantic Taskforce on Antimicrobial Resistance (TATFAR) US and EU collaboration focused on antimicrobial resistance Activities relevant to preserving antimicrobials Set of 17 recommendations Recommendation 1 Develop common structure and process indicators for hospital antimicrobial stewardship programmes http://www.ecdc.europa.eu/en/activities/diseaseprogrammes/tatfar/documents/210911_tatfar_report.pdf
Assessment of Antimicrobial Stewardship Programs European Examples United Kingdom Antimicrobial self-assessment toolkit (ASAT) Web-based assessment instrument for acute care facilities France Identify areas for improvement or prioritization Assess longitudinal progress in stewardship Benchmark with similar organizations Mandatory annual public reporting of antibiotic practices Nine measures reported (20 point total score) Higher resource score was associated with less antibiotic use, particularly for facilities with IT support Cooke J, et al. J Antimicrob Chemother, 2010. 65(12): p. 2669-73. Amadeo B, et al., J Antimicrob Chemother, 2011. 66(2): p. 434-42.
Goals for a CDC Antimicrobial Stewardship Assessment Define minimum expectations for optimizing antimicrobial use and addressing resistance Determine current stewardship activities at individual acute care facilities Track progress over time (GAIN Act) Understand needs and offer support for activities
Indicator Types Indicators Structure Process Outcomes Examples Program infrastructure Policies & guidelines Adherence to recommended practices Antimicrobial use (process /outcome) C. Diff infections Resistance patterns
Checklist for Facilities Minimal expectations focused on core functions Leadership and management Practices that support appropriate use Monitoring use and practices Education / Information sharing
Proposed Stewardship Checklist 1. Does this facility have a physician leader identified to optimize antibiotic use? 2. Does this facility have a pharmacist leader identified to optimize antibiotic use? 3. Does facility leadership support efforts to optimize antibiotic use at this facility? 4. Is there at least one intervention to optimize antibiotic use integrated into clinical care at this facility? 5. Does this facility monitor antibiotic use? 6. Is information on optimizing antibiotic use provided to prescribers at least annually?
Physician and Pharmacist Leadership Core contributors to a stewardship committee More specific than Does your facility have a stewardship committee or team In recent assessment of stewardship in Georgia, 26 of 50 facilities reported having a multidisciplinary committee focused on antimicrobial use 19 (73.1%) reported both physician and pharmacist leaders for stewardship activities, but 4 (15.4%) had neither a physician nor a pharmacist leader 3 (11.5%) did not meet regularly
Interventions to optimize antibiotic use Facilities can select from a list of activities Activities will align with IDSA/SHEA guideline strategies or more recent published studies Example activities: Specified antimicrobial agents need to be approved by a physician or pharmacist prior to dispensing (i.e., preauthorization) A physician or pharmacist reviews incoming prescriptions for specified antimicrobial agents (i.e., prospective audit) Order entry system has imbedded clinical decision making support for prescribing antimicrobials Antimicrobial prescriptions subject to time-sensitive automatic stop orders
Monitoring Antibiotic Use Consumption Pharmacy purchasing data Dollars per patient per day or defined daily dose (DDD) Antimicrobials administered to patients per day Days of therapy (DOT) Compliance Adherence to facility-specific guidelines Compliance with antimicrobial policy or protocol Assessment of appropriateness
Final thoughts Stewardship programs can differ among facilities Goal is to balance: specific yet adaptable Growing need for stewardship measures Structure and process measures are an acceptable start Visible results beyond infrastructure and activities are needed Outcomes measures Proof of true clinical impact
HICPAC Discussion Do these domains capture core functions of effective antimicrobial stewardship? Leadership and management Practices that support appropriate use Monitoring use and practices Education / Information sharing
HICPAC Discussion Minimum expectation checklist indicators Do the proposed six checklist questions reflect acceptable minimum expectations for a hospital antimicrobial stewardship program? Are they Relevant? Feasible? Valid?
Proposed Stewardship Checklist 1. Does this facility have a physician leader identified to optimize antibiotic use? 2. Does this facility have a pharmacist leader identified to optimize antibiotic use? 3. Does facility leadership support efforts to optimize antibiotic use at this facility? 4. Is there at least one intervention to optimize antibiotic use integrated into clinical care at this facility? 5. Does this facility monitor antibiotic use? 6. Is information on optimizing antibiotic use provided to prescribers at least annually?
HICPAC Discussion Does the term Program imply a burden? Alternative terms to a stewardship program Stewardship interventions? Core functions? Principle practices? Safe prescribing practices?
Thank you! Loria Pollack, MD, MPH Arjun Srinivasan, MD, FSHEA CDC/Division of Healthcare Quality and Promotion For more information please contact Centers for Disease Control and Prevention 1600 Clifton Road NE, Atlanta, GA 30333 Telephone, 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348 E-mail: cdcinfo@cdc.gov Web: www.cdc.gov The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. National Center for Emerging and Zoonotic Infectious Diseases Division of Healthcare Quality Promotion