Antimicrobial Stewardship
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Transcript of Antimicrobial Stewardship
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Antimicrobial Stewardship
St. Mary’s Hospital Infection Control Committee
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What is Antimicrobial Stewardship
• An interdisciplinary team dedicated to practices that improve appropriate selection, dosing, route, and duration of antimicrobial therapy
• The ultimate goal of antimicrobial stewardship is to improve patient care and health care outcomes
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Antimicrobial Stewardship Team• Infectious Disease Physician• Clinical Pharmacist• Clinical microbiologist• Information System
Specialist• Infection control
professional• Hospital epidemiologist• Leadership support
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Elements of an Antimicrobial Stewardship Team
• A comprehensive program will include:– Active monitoring of resistance– Fostering of appropriate antimicrobial use– Collaboration with an effective infection control
program to minimize secondary spread of resistance is considered optimal
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Elements of an Antimicrobial Stewardship Program
• Prospective audit with intervention and feedback
• Formulary restriction and preauthorization
• Guidelines and clinical pathways
• Antimicrobial cycling• Antimicrobial Order Forms• Monitoring of progress and
outcome measures
• Education• De-escalation of therapy• Dose optimization• Conversion from parenteral
to oral• Computer
Surveillance/Decision Support
• Microbiology Laboratory
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Prospective audit,intervention,and feedback
• Have the clinical pharmacist on the floor making recommendations about appropriate antibiotic, route, length of therapy
• Probiotic Protocol to prevent C. Diff
• Focus on one floor for recommendations
• Up to a 37% reduction in the number of days of inappropriate antibiotic use.Approx. $400.00 cost savings per patient
• While assessing patients for probiotics look at de-escalating of antibiotics
• Decrease rate of C. Diff
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Formulary restriction and preauthorization requirements for specific agents
• Control of certain antibiotic use through Pharmacy and Therapeutics Committee can be very effective
• Control of Cleocin use has led to prompt cessation of nosocomial outbreak of C. Diff
• Restriction of Vancomycin and third generation cephalosporins in response to VRE has demonstrated mixed results
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Education• Conference Presentations • Student teaching• E-mail alerts• Provision of written
guidelines• Peri-operative area order
forms• Share results of audits
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Guidelines and Clinical Pathways• Implementation of guidelines
incorporating local microbiology and resistance patterns
• Balance antibiotics in HAP and VAP patients
• Use algorithms incorporating the clinical pulmonary infection score
• Leads to decreased duration of therapy,decreased VAP recurrence, decrease of multi-drug resistance patterns
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Antimicrobial Cycling• Slows spread of
resistance• Most popular is
Gentamicin to Amikacin• Ceftazadime for
Ciprofloxacin lead to a decreased incidence of VAP
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Antimicrobial Order Forms• Use of Peri-operative
prophylactic order forms with automatic stop at 2 days (SCIP Guidelines)
• Pneumonia Order set (Pneumonia core measures) with 6 different pneumonia indications and drugs
• Order forms facilitate implementation of practice guidelines
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Streamlining or De-Escalation of therapy• Continuing excessive broad therapy contributes to the selection of
antimicrobial resistant pathogens• When culture results become available we can streamline or de-
escalate antimicrobial therapy to more targeted therapy that decreases antimicrobial exposure and contains cost
• This can also lead to avoidance of redundant inpatient antibiotic- days
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Dose Optimization• Dosing that accounts for
individual patient characteristics (age,weight,renal function)
• Site of infection• Pharmacokinetics -Vancomycin
and aminoglycosides• Optimize antimicrobial
pharmacodynamics of the drugs B-lactams and fluoroquinolones
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Conversion from parenteral to oral therapy
• Having a systematic plan for switching from parenteral to oral treatment may have an added benefit of aiding in early hospital discharge planning
• Development of clinical criteria and guidelines allowing conversion can facilitate implementation.
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Computer Surveillance / Microbiology
• Add cost codes to antimicrobial susceptibility data
• Antimicrobial report to pharmacy
• Vancomycin dosing/utilization sheet
• Review antimicrobial errors• Leap frog to CPOE
• Actively involved in resistance surveillance
• Update antibiogram annually
• Make easily accessible to physicians
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St.Mary’s Antibiotic Stewardship Efforts to Date
• Probiotic Protocol• Antibiogram on line• Pneumonia Order sets• Pharmacokinetics• Peri-op Area Guidelines• IV to PO conversion• Culture results from lab• Pharmacy/IS generated
pneumonia vaccine program
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What does our future hold for Antibiotic Stewardship
• Assign antibiotic rounds to new pharmacy school professor ( de-escalating and streamlining)
• Follow culture results from lab
• Approve IV to PO conversion automatic by pharmacist
• Finish 6 month Probiotic study
• Work on Vancomycin Order form
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Antibiotic Stewardship 2013
0
20
40
60
80
100
120
140
Jan-1
4
Mar
-14
May
-14
Jul-1
4
Sep-1
4
Nov-14
#Interventions
% Acceptance
15.5
16
16.5
17
17.5
18
18.5
1stQtr 2ndQtr 3rd Qtr 4th Qtr
TARGETAthens cost per dischargeTotal Savings 2013 $15,458
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Change Dose
Change Antibiotic
IV to PO conversion
DiscontinueTherapy
Add an antibiotic
Renal dosing
Streamline Other: Probiotic
Accepted 1
10 21 28 1 15 2 8
Not accepted
5
6 3 1
Total 1 15 27 31 2 15 2 8
Documentation of Interventions by type
MONTH : SEPTEMBER 2013Total Antibiotic Interventions:100
Percent Accepted: 85%
• April Ecker and Gin Fleming (Antibiotic Pharmacist)
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C.H.E. Act Initiatives Thru September 2013
0
5
10
15
20
25
2011-2013 Target
Cost peradjusteddischarge
0
1
2
3
4
5
6
7
8
9
Mar
-12
May
-12
Jul-1
2
Sep-1
2
Nov-12
Jan-
13
Mar
-13
May
-13
Jul-1
3
Sep-1
3
Target
Asthma Drugs Cost peradjusted discharge
0.7
0.75
0.8
0.85
0.9
0.95
1
Mar-13
Apr-13
May-13
Jun-13
Jul-13
Aug-13
Sep-13
Oct-13
TARGET
PPI COST PER ADJUSTEDDISCHARGE
0
1
2
3
4
5
6
7
Mar-13
Apr-13
May-13
Jun-13
Jul-13
Aug-13
Sep-13
Oct-13
Target
Anticoag cost peradjusted discharge
Anti-infectives (Antibiotics)
Anticoagulants
Asthma Drugs Proton Pump Inhibitors
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ACT-Medication ManagementAnti-Infective Stewardship Initiative
2010
$0.00
$5.00
$10.00
$15.00
$20.00
$25.00
$30.00
Cost per adjusteddischargeSt. Mary's 2010Target
2010 Target