Antimicrobial Stewardship: The Premier Health Experience Steve Burdette, MD, FIDSA Professor of Medicine Wright State University Boonshoft School of Medicine Director of Antimicrobial Stewardship Miami Valley Hospital and Premier Health Dayton, Oh
The time has come to close the book on infectious diseases. We have basically wiped out infection in the United States. William Stewart United States Surgeon General 1967
What is Antimicrobial Stewardship? We are the antibiotic police according to some, but really we are just monitoring and advising on antimicrobial therapies De-escalation or at times escalation Duration of therapy!!! Appropriateness of therapy Dose optimization** Why is ASP required clinically Minimal new antibiotic therapeutic classes in the horizon Increasing drug resistance Lab conduit for better testing (PCT, rapid diagnostics, etc) Provider education on key ID issues / policies / procedures Review and update order sets / develop treatment guidelines for select infections Ensure that antibiotics are being given when desired / required Physician documentation leaves a lot to be desired
New Agents 2018 and beyond Available Delafloxacin Quinolone with activity against MRSA and Pseudomonas Meropenem / vaborbactam CRE Ceftazidime / avibactam CRE, ESBL, +/- MDR Pseudomonas Ceftolozane / tazobactam MDR Pseudomonas Pending FDA approval Plazomicin (aminoglycoside) CRE Cefiderocol Acinetobacter CRE Lefamulin CAP and MRSA Imipenem / relabactam CRE
Consequences of Antimicrobial Misuse Unnecessary exposure to antimicrobials results in risk to patients with no clinical benefit Adverse drug effects 25% of reported ADEs involve antimicrobials Drug-drug interactions Hypersensitivity reactions Organ dysfunction Antimicrobial resistance Clostridium difficile Increasing incidence and severity Bates DW et al. JAMA 1995;274:29-34
Why is ASP required politically Upcoming requirement for participation for CMS Indications for use 48 hour review of antibiotics Mandated by the Joint Commission as of 1/1/17 8 core principles that we have to meet Insurance carriers are using ASP as part of their score cards for reimbursement
Goals of stewardship Optimize Safety Reduce Resistance Decrease/ Control Health care $$
Stewardship
CDC elements
Leadership skills of stewards
What is the low hanging fruit in ASP? Duration, duration, duration De-escalation Stopping when MRSA testing is negative Using cefazolin instead of ceftriaxone Education Text books and practice patterns are out of date Microbiology reporting Cascading of cephalosporin's Reporting of certain drugs for certain cultures
Miami Valley Hospital Level 1 Trauma Center ~800 beds Typically have 200-250 patients per day on systemic abx NICU 80+ ICU beds (surgical, neuro, medical, CT, burn) 3 ID groups 1 Private 1 Hospital Owned 1 Academic
How do we do stewardship inside the hospital? Pharmacist reviews patients based on various criteria Physician and pharmacist review the patients together Recommendations are past along via secure texting to the providers Recommendations are suggestions, they are not required to follow
ASP focus ICU patients Surgical and medical ICU's are teaching services Triple antibiotics Unless in septic shock or MDR pathogens, we try and stop all triples Select units (pulmonary, surgical units) Hospitalists Easiest communication High point scores High cost antibiotics Cellulitis (broad spectrum agents when Gram + coverage will suffice) Stay away from diabetic foot infections Duration of therapy > 7 days (levaquin >5 days)
Detailed records
AMS review
Our basic approach to ASP.. Expensive drugs are at times the best option..other times they are overkill Still lots of confusion between ceftolozane/tazobactam and ceftazidime/avibactam We are not cost cops But if an expensive drug is not needed, we will push to get it stopped Daptomycin for cellulitis (use linezolid if not responding to vancomycin) We will do what we think is best for the patient Cut costs by decreasing duration of therapy and deescalating to appropriate therapy
Antibiotic de-escalation Going from cefepime to ceftriaxone for a pansensitive E coli is NOT deescalating Using cefazolin in the ICU for a pan-sensitive E. coli sepsis is de-escalating We love giving amoxicillin or cephalexin / cefazolin in the ICU!!!
Medication management
Critical Access Hospital
CAH Core Elements
Indications for use Make them work for you!!
Check points
Risk analysis
Detailed log
CAH protocols
Antibiotic restrictions at MVH Ceftaroline Daptomycin Tedizolid Fidaxomicin (GI and ID) Isavuconazole (by select indications / conditions) Tigecycline
Out of Date
Clostridium difficile and antibiotic exposure
Antibiotic choice
ICU Respiratory Cultures And the role of triple antibiotics (i.e. MRSA + dual gram negative coverage)
Pseudomonas aeruginosa % susceptible n=36 Add Levoflox Add tobramycin Pip Tazo 78% 80.5% 88.9% Cefepime Add intermediate 66.7% 88.9% 66.7% 88.9% 72.2% 94.4% Meropenem 94.4% 94.4% 97.2% Aztreonam Add intermediate 61.1% 77.8% 69.4% 83.3% 77.8% 94.4%
All gram negative HCAP and HAP isolates N=135 Add levoflox Add tobramycin Pip tazo 87.7% 91.4% 90.8% Cefepime 86.6% 88.8% 89.6% Meropenem 95.5% 96.3% 97%
Data to action
Track something!!!
Antimicrobial Days of Therapy Definition: any dose of any antibiotic on a given day = one day of therapy (DOT) Normalize to 1000 pt days Antimicrobials monitored since program started aztreonam, ceftriaxone, cefepime, piperacillin/tazobactam, ertapenem, meropenem, levofloxacin, tigecycline, vancomycin, linezolid, ceftaroline, daptomycin
1.1 MVH all ICU days of therapy, as % of baseline MVH All ICU Days of Therapy as a % of Baseline 1 0.9 0.8 0.91 0.92 0.7 0.86 0.6 0.81 0.78 0.86 0.71 0.84 0.5 baseline 4q14 1q15 2q15 3q15 4q15 1q16 2q16 3q16 MICU SICU NSIC All ICUs
Acute care settings
Recommended FTE
Predicted effectiveness, staffing levels
Rates over 1,000 patient days 850 MVH ICU Rolling 12 Month Average DOT / 1000 Pt Days 800 750 700 650 600 550 500
Total view
MVH Days of Therapy Baseline (3/14-8/14) 4 qtr 2014 4.4% 2015 3.5% 2016 5% 2017 Cumulative Decrease in DOT / 1000 Patient Days of 15.2% 3.4%
Total ICU Days of Therapy Baseline 4 qtr 2014 8.2% 2015 6.9% 2016 7.1% 2017 1% Cumulative Decrease in DOT / 1000 Patient Days of 21.2%
2017 Metrics Compliance with CMS / TJC Patient education Physician credentialing 48 hour review Website development Decrease DOT by 3% Site specific metric C diff review Review for antibiotic de-escalation, treatment congruent with guidelines, and concurrent PPI use Cellulitis; use of broad spectrum antimicrobials
2018 Metrics Maintain our days of therapy without increase Minimize metronidazole use for Clostridium difficile to less than 20% of the patients Improve antibiotic compliance with sepsis measure to >90% Intervene on all bacteremic patients Education of the medical staff 8x per year
Our experience. Big dollar savings initially But that is likely over No impact on C diff (yet) PPI stewardship Cutting antibiotics will not help if there is a hand hygiene compliance issue No impact on LOS in the ICU despite cutting antibiotics by 20-30% But it did not go up When big brother stops watching all your work goes up in smoke! You have to keep working!
How can you make a difference in your facility
Low hanging inpatient conditions Asymptomatic bacteriuria Duration of antibiotics for CAP Triple Antibiotics for PNA De-escalation Avoiding gram negative agents for cellulitis These impact Infection Control issues greatly!!!
ASP literature to minimize antibiotic use JAMA study 2016 5 days for CAP HAP/VAP guidelines 7 days is enough unless slow clinical response UTI Treatment of asymptomatic bacteriuria actually leads to more UTI s Culture of culturing for foley catheters STOP-IT study 4 days for intra-abdominal infections after source control I am not a believer of this study!
IDSA guidelines for asymptomatic bacteriuria in adults
Gender factors
Culture of culturing Obtain urine cultures in hospitalized patients with urinary catheter only when one of the following criteria are met: Local signs and symptoms of infection (supra-pubic tenderness, CVA tenderness etc.) Fever and neutropenia Fever and kidney transplant Fever and recent uro-genital procedure Fever and obstructed catheter Other: document rationale for ordering the culture (EMR will force provider to document reasons in EPIC and/or progress note) Mullin KM, Kovacs CS, Fatica C et al. A Multifaceted Approach to Reduction of Catheter-Associated Urinary Tract Infections in the Intensive Care Unit with an Emphasis on "Stewardship of Culturing". Infect Control Hosp Epidemiol 2017 Feb;38(2):186-188.
Blood cultures Culture of culturing, cont d Peripheral only Confirming they have a fever before cultures Role of procalcitonin
Diagnostic stewardship
C diff stewardship Considered tests to be truly positive if tested patients met the following criteria: 3 episodes of diarrhea within 24 hours in the absence of administration of a laxative and at least 1 of the following symptoms: (1) temperature 38 C, (2) abdominal pain, (3) abdominal tenderness documented on exam, (4) white blood cell count >12,000/µL. Positive tests that did not meet these criteria were deemed falsely positive.
C diff stewardship, cont d Major education regarding prior data Two diagnostic stewardship measures were implemented via the microbiology laboratory in January 2017. C. difficile NAAT orders were canceled via the Laboratory Information System (LIS) if a stool sample was not received within 24 hours of order placement. Second, the laboratory initiated a stick test on nonliquid samples such that stool samples viscous enough to support a stick s upright position were rejected for testing.
Four core measures
Pneumonia trial
Increasing evidence to support short treatment courses Disease Short course Long course Community Acquired PNA 3-5 7-10 Hospital acquired PNA 7-8 10-15 Pyelonephritis 5-7 10-14 COPD exacerbation <5 >7 Bacterial sinusitis 5 10 Cellulitis 6 10 Adapted from: Spellberg B. JAMA Intern Med 2016;176(9):1254-5
Nasal screening options
MRSA pneumonia
Pneumonia Hospital-Acquired Pneumonia Ventilator Associated Pneumonia Community-acquired Pneumonia MDR Risk Factors Present No MDR Risk Factors
Increased ED resources ASP wish list to make a bigger Resources for DC medication reconciliation / evaluation of duration of therapy Area of antibiotic overuse and prolonged courses of therapy More EHR tools to trigger de-escalation impact An easy fix for 48 hour antibiotic time out
Questions?