Antimicrobial Stewardship:A Ministry Approach

J Gavin Cotter MD MPHDirector Antimicrobial StewardshipUICOMP Assistant Professor of Clinical MedicineInfectious Disease

OSF Healthcare

• Owned and operated by The Sisters of the Third Order of St. Francis, Peoria, Illinois.

• 11 acute care facilities• 1 Hospice House• OSF Prompt Care• 2 Colleges of Nursing• OSF Medical Group

OSF Healthcare: Hospitals

• Saint James-John W Albrecht Medical Center– Pontiac, IL– Beds: 42

• Saint Joseph Medical Center– Bloomington, IL– Beds: 149

• Saint Luke Medical Center– Kewanee, IL– Beds: 25

• Saint Francis Medical Center– Peoria, IL – Beds: 609

• Holy Family Medical Center– Monmouth, IL – Beds: 23

• Saint Anthony’s Health Center– Alton, IL– Beds: 203

• Saint Mary Medical Center– Galesburg, IL– Beds: 90

• Saint Elizabeth Medical Center– Ottawa, IL– Beds: 97

• Saint Anthony Medical Center– Rockford, IL– Beds: 254

• St. Francis Hospital and Medical Group– Escanaba, MI– Beds: 25

• Saint Paul Medical Center– Mendota, IL– Beds: 25

OSF ASP Aims

• To create a formalized Inpatient ASP at OSF SFMC.

• To support pre – existing inpatient efforts within OSF Healthcare and transition these efforts into formalized Inpatient ASPs.

• To create new inpatient ASPs within OSF Healthcare.

• To develop an Ambulatory ASP within OSF Healthcare.

Steps

• Process Redesign• Formed a Powerful Coalition• Created a simple vision:

OSF SFMC ASP Action Items

• Order sets– PNA – CAP/HCAP– Sepsis

• TheraDoc® EZ-Alerts • SCIP• Drug Reviews• Education• Branding – “The antibiotics people.”

OSF ASP Aims

• To create a formalized Inpatient ASP at OSF SFMC.

• To support pre – existing inpatient efforts within OSF Healthcare and transition these efforts into formalized Inpatient ASPs.

• To create new inpatient ASPs within OSF Healthcare.

• To develop an Ambulatory ASP within OSF Healthcare.

OSF Healthcare: Vision

• Embracing God's great gift of life, we are One OSF ministry transforming health care to improve the lives of those we serve.

SAMC and SJMC

• TheraDoc® EZ-Alerts• Established PharmD ID position at Rockford• Vanco/Aminoglycosides Protocols

Centers of Innovation• IV to PO• CRRT dosing

SAMC Levofloxacin Utilization

OSF ASP Aims

• To create a formalized Inpatient ASP at OSF SFMC.

• To support pre – existing inpatient efforts within OSF Healthcare and transition these efforts into formalized Inpatient ASPs.

• To create new inpatient ASPs within OSF Healthcare.

• To develop an Ambulatory ASP within OSF Healthcare.

SMMC and SJMC- Pontiac

• Consolidate Improvements and Produce Still More Change– Education Efforts- Visiting lectures– Speak directly to Local Administration– Pharmacists Trained in ASP– Identify Local Champions

IDPH Collaborative

• Illinois Collaborative for Hospital Antimicrobial Stewardship Enhancement(ICHASE)

OSF Facilities Participating Saint Joseph Medical Center

Zosyn® Saint James-John W Albrecht Medical Center

Levaquin Saint Mary Medical Center

Levaquin Saint Francis Medical Center

Meropenem Saint Anthony Medical Center

Levaquin and Zosyn®

Levofloxacin Criteria for UseLevofloxacin (Levaquin)

1. PO tx of CAP following response to empiric tx with ceftriaxone + azithromycin2. IV tx CAP if severe allergy to cephs3. Bacterial enteritis/colitis + metronidazole4. Prostatitis

5. Single dose ppx prostate needle biopsy6. sensitive gram negative bacteremia7. S. pneumo bacteremia when patient allergic to beta-lactams

Piperacillin/Tazobactam (Zosyn®) Criteria for Use

Zosyn 1. Suspected or documented P. aeruginosa infection2. cystic fibrosis

3. Intra-abdominal with Healthcare associated risk

4. Health care and Hospital Associated Pneumonia5. Severe diabetic foot with osteomylitis: +/- wet gangrene 6. neutropenic fever with suspected typhlitis8. Necrotizing Pancreatitis

Meropenem Criteria for Use

MeropenemCurrent or history of ESBL Positive OrganismCurrent or history of MDR PseudomonasCRE in combination with Colistin and ID consultCurrent or History of Other MDR Gram negative organismNeutropenic fever with suspected typhlitis

Necrotizing PancreatitisFailed, had ADE, or have allergy (rash or hives) to standard treatment (standard treatment = zosyn or cefepime)

SAMC Piperacillin/Tazobactam Utilization

SMMC Levofloxacin Utilization

SJMC Levaquin Utilization

OSF ASP Aims

• To create a formalized Inpatient ASP at OSF SFMC.

• To support pre – existing inpatient efforts within OSF Healthcare and transition these efforts into formalized Inpatient ASPs.

• To create new inpatient ASPs within OSF Healthcare. More to do!

• To develop an Ambulatory ASP within OSF Healthcare.

OSF Medical Group: A revisited opportunity.

• 1st attempt 2011– Failure

• Plea for help – 2014– Clostridium Difficile

• A major problem in both inpatient and outpatient settings throughout the ministry.

• At SFMC 85% of cases originate as outpatient.• Order set revised 2012, then again 2014.• Multiple Service lines concerned.• Administrative support

New Outpatient ASP

• C diff collaborative created• Outpatient:

– Identify most commonly used antimicrobials– Identify most common infectious diagnoses

• Education curriculum developed• Outpatient Infusion Center

– Algorithm– Request reviews

Greatest Lessons Learned

• Attitudes, Knowledge, Beliefs• Communication• Branding• Data• IT is not a barrier• Outpatient ASP is a very different culture than

Inpatient ASP