Antimicrobial Stewardship ForumAntimicrobial Stewardship Forum

7 April 20117 April 2011

Time line of the rapid rate of resistance

Comprehensive AMS programs

• antimicrobial use 22 – 36% 1

• Save US$200K – 900K p.a1

• Similar savings in Australian programs

Improving antimicrobial prescribing

• treatment failures, mortality, LOS 2

• incidence of nosocomial CDI2

1. Dellit Owens et al Clin Inf Diseases 2007 2. Davey, Brown et al Cochrane Database Systematic Review 2009

Antimicrobial Stewardship

Antimicrobial Stewardship

• Priority recommendation from Reducing harm to patients: the role of surveillance 2007

• Priority for Commission– Antimicrobial Stewardship Committee– Antimicrobial Stewardship Forum 2008– Windows into Safety & Quality 2009; 2010– Antimicrobial Stewardship in Australian Hospitals 2011

• November 2008 noted by Health Ministers

• AMR is a focus of 2011 World Health Day

• National Safety & Quality Health Care Standards

• AMS implementation plan supported by Commission standing committees

EditorsMargaret DuguidMarilyn Cruickshank

ContributorsKirsty Buising Celia Cooper Margaret Duguid John FergusonLyn Gilbert David KongDavid Looke David Maxwell Karen Thursky John TurnidgeHelen van Gessel

AMS in Australian Hospitals

Antimicrobial Stewardship Advisory Antimicrobial Stewardship Advisory CommitteeCommittee

Dr Celia CooperDr Celia Cooper

Site Clinical Director & Head, Site Clinical Director & Head, Microbiology & Infectious Diseases Microbiology & Infectious Diseases

SA Pathology, WCH SiteSA Pathology, WCH Site

Antibiotic Stewardship - Definition

The optimisation of antibiotic utilisation

The appropriate use of antibiotics and the limitation of unnecessary antibiotic administration/exposure

Optimising diagnosis

Selecting appropriate antibiotics

Optimal dosing

Australian Commission on Safety & Quality in Health Care (ACSQHC)

“National strategic framework and associated work program”

Health Care Associated Infections (HAIs) are one of the key areas

HAIs nominated as one of the priority areas for 2007/10

HAI Strategy – 5 Key Initiatives

National surveillance for the prevention of HAIs

Building Clinician Capacity Project

National Infection Control Guidelines

National Hand Hygiene Project

Antimicrobial Stewardship Project

Antimicrobial Stewardship Advisory Committee

Aim: to promote the optimal use of antimicrobials to maximise treatment efficacy in individuals while minimising the impact of antimicrobial resistance on communities

Focus on developing strategies at the national, state, institutional and community levels

ACSQHC AMS Advisory Committee - MEMBERS

Celia Cooper (Chair)

Kirsty Buising

John Ferguson

David Kong

David Looke

Graeme Nimmo

John Turnidge

Karen Thursky

Tara Anderson

Morgyn Warner

Helen Van Gessel - retired

David Maxwell - retired

SUPPORT

Chris Baggoley

Marilyn Cruickshank

Margaret Duguid

Emily Parker

Tom Sanders

Vesna Morosin (NHMRC Observer)

Work of the Antimicrobial Stewardship Committee

All members of the committee will have an equal opportunity to contribute to the end result

Each committee member is responsible for developing a particular part of the strategy

Strategy influenced by input from first Antimicrobial Stewardship Forum in 2008

Work Program of the Antimicrobial Stewardship Committee

10 Key components

Each one is the responsibility of a committee member

The program is divided into:• Strategies for antimicrobial stewardship

• Resources

• Evaluation, audit and feedback

Strategies for Antimicrobial Stewardship

Persuasive/EducationalEducation of prescribers, including the impact of the pharmaceutical industry – Celia CooperRestrictivePre-prescription

Formulary restriction, antimicrobial cycling and antimicrobial approval systems – Kirsty Buising

Post prescription

Review of antimicrobial use with direct interaction and feedback to the prescriber – David Maxwell

Point of care interventions – John TurnidgeDirected antimicrobial therapy on the basis of culture resultsDose optimisationParenteral to oral conversion

Resources

Personnel

Effective institutional antimicrobial stewardship teams (including governance) – Helen Van Gessel

Role of clinical microbiologists and laboratory – John Ferguson

• Antibiograms• Selective reporting

Resources (cont)

Personnel (cont)Role of infectious diseases physicians (local policy development) –Celia CooperRole of Pharmacists – Margaret DuguidTools

Integration of stewardship programs into electronic decision support systems and new technology platforms – Karin Thursky

Evaluation, Audit and Feedback

Effective use of collective surveillance data – David Looke

Work Program of the Committee

Each member conducted a literature search and presented the published evidence of efficacy (or otherwise) of the strategies assigned to them by the committee

These literature searches and associated recommendations have been assembled into a book edited by Marilyn Cruikshank and Margaret Duguid. This book has been launched today

Key points and recommendations have been distilled from the book chapters to describe the minimum acceptable response to antibiotic stewardship by institutions. These are included at the beginning of each chapter

Work of Antimicrobial Stewardship Committee - Summary

The ACSQHC’s first Antimicrobial Stewardship Forum highlighted a need for a “blue print” to establish antimicrobial stewardship programs in individual hospitals as well as at the State and National level

On this basis, the Committee developed “Antimicrobial Stewardship in Australian Hospitals”

“Antimicrobial Stewardship in Australian Hospitals”

10 chapters summarising current evidence about AMS programs and their implementation in hospitals

Chapters 1-6 – strategies for implementing and sustaining AMS

Chapters 7-10 – resources required for AMS

Implementing a program (Chapter 1) (HVG, MD)

Change management

Governance, executive support

AMS team, engaging clinicians

Program plan

Goals and measuring improvement

Selecting strategies

Strategies for Implementing AMS

Restrictive (Chapter 2) (KB)Formulary restrictionantimicrobial approval systems

Persuasive (Chapter 3) (DM)Review and prescriber feedbackdirect interaction and feedback to the prescriber

Point of care interventions (Chapter 4) (JT)Directed antimicrobial therapy on the basis of culture resultsDose optimisationParenteral to oral conversion /Educational

Strategies for AMS

Measuring performance – Chapter 5 (DL, MD)Monitoring use

Quantity (pharmacy data)Quality (DUE, Point prevalence studies)

Process and outcome indicators

Education – Chapter 6 (CC, MD)Education of prescribers, including the

impact of the pharmaceutical industry

Strategies for AMS

Resources for AMS

Clinical microbiology services – Chapter 7 (JF)AntibiogramsSelective reporting

Infectious diseases services – Chapter 8 (CC, MD)Leadership, approval systemsPolicies, guidelines, education

Pharmacy services – Chapter 9 (DK, MD)Roles and responsibilities of ID/AMS pharmacistsFormulary management, restrictions, DUE

Resources for AMS

E- Systems (Chapter 10) (KT)Integration of stewardship programs into electronic decision

support systems and IT platforms

AppendicesAntimicrobial usage: monitoring and analysis

Examples of policies, guidelines education material from Australian hospitals

List of useful websites

Guidelines, policies on managing conflicts of interest, liaison with pharmaceutical industry

Aims for Today’s Forum

Launch book “Antimicrobial Stewardship in Australian Hospitals”

Review the key messages in the book

Describe the on-going work program for the Committee

Snapshot of current state of AMS across Australia

Be inspired by examples of successful/innovative programs

Aims for Today’s Forum (cont)

Seek feed-back from attendees regarding recommendations from the book.

Seek feed-back from attendees at the forum regarding the planned work program

What are the likely barriers to implementing the recommendations?

How can the ACSQHC help clinicians and hospitals to implement successful AMS programs?

Aims for Today’s Forum (cont)

All this information will guide the Committee’s next work program

National ActivitiesAntimicrobial Stewardship

Margaret DuguidPharmaceutical Advisor

Australian Commission on Safety and Quality in Healthcare

7 April 2010

• Requirements for AMS programs

• Current status of AMS in Australia

• AMS work plan 2011-2012

• Next steps

Overview

1. Structure and governance of the program

2. Essential strategies for all hospitals

3. Activities according to local priorities and resources

Requirements for AMS programs in Australian hospitals

Structure and governance of the program

Hospital management support for:• dedicated resources for stewardship activities, education, and

measuring and monitoring antimicrobial use

• multidisciplinary AMS team. Core membership (wherever possible) ID physician, clinical microbiologist or nominated clinician, and a clinical pharmacist

• AMS resides within hospital’s quality improvement and patient safety governance structure. Clear lines of accountability between AMS team AND chief executive; clinical governance; drug and therapeutics, and infection prevention and control committees.

Requirements for AMS programs in Australian hospitals

Essential strategies for all hospitals• implementing clinical guidelines

consistent with Therapeutic Guidelines: Antibiotic and local antimicrobial susceptibility patterns

• formulary restriction and approval systemsbroad-spectrum and later generation antimicrobials

• review antimicrobial prescribing with intervention and feedback—at a minimum for ICU patients

• monitoring performance of antimicrobial prescribing. unit or ward-specific use data; auditing antimicrobial use; QUM indicators

Requirements for AMS programs in Australian hospitals

Requirements for AMS programs in Australian hospitals

Activities according to local priorities and resources• education - prescribers, pharmacists and nurses

good antimicrobial prescribing practice and AMR

• point-of-care interventions– streamlining or de-escalation of therapy– dose optimisation– parenteral-to-oral conversion

• information technology - electronic prescribing withclinical decision support or online approval systems

• facility-specific antimicrobial susceptibility datapublished annually

Gram Po sit iveStaphylococcus aureus #

Coagulase negative staph #

Enterococcus #

Strep pneumoniae# 12

Gram N eg at iveEscherichia coli #Klebsiella species #Haemophilus inf luenzae 42Stenotrophomonas maltophil 21Pseudomonas species #Acinetobacter species¶ 17Enterobacter species¶ 86Proteus mirabilis 55Serrat ia species¶ 22Citrobacter species¶ 33M organella morganii¶ 30*Amoxycillin provides similar cov***Cef ot axime provides similar cover**Cephazolin provides similar cov§Meropenem provides similar cover

70-89% sensit ive >=90% sensit iveNot report ed Blank <70% sensit ive

# St rep pneumoniae 73% Fully sensit ive,

¶ Don't use Cephalosporins - even if report ed sensit ive

Int ermediat e18%

Whole Hospita l

XXX HospitalAntibiotic sensitivity profile

Data from 1/1/200X to 31/3/200X

• Snapshot of AMS in Australian hospitals• surveys to 281 hospitals (Directors of

pharmacy)• 29% response rate• 25% had AMS team/committee• 18% AMS Team rounds to some wards• 8% regular AMS team rounds• 30% participated in NAUSP

Current status of AMS programs

Chen AWJ, Khumra S et al J Pharm Pract Res 2010;40:19-25

Barriers faced at 80 hospitals Percentage (%)

Insufficient education & training 1.Senior doctors and visiting medical officers2.Junior doctors3.Nursing staff

34.627.217.3

Lack of resourcesInadequate clinical pharmacy servicesNo access to Infectious Disease consult serviceInadequate financial support to promote and maintain Antimicrobial Stewardship

28.423.521.0

Prescribing culture of the organizationCulture of the organization –resistant to changesLack of ownership of the ASP-related activitiesLack of clinical leadership to promote Antimicrobial Stewardship

26.627.221.0

Lack of feedbackLack of feedback to prescribers on antimicrobial prescribing patterns

22.2

Country comparisonCountry Comparison AMS Acivities

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BelgiumUSAustralia

Country Comparison

1. Van Gastel E, et al J Antimicrob Chemother Jan 20102. Pope SD, Dellit TH, Owens Rd et al Infect Control Hosp Epidemiol 2009;30:97-8

3. Chen AWJ, Khumra S et al J Pharm Pract Res 2010;40:19-25

Country Comparison

010

203040

506070

8090

Streamlining Parenteral to oralconverstion

Automatic stop orders

Belgium [1]

US [2]

Australia [3]

2011-2012 Work Program for Committee

Activity Timeline

Antimicrobial stewardship workshop 7 April 2011

Webinar on using antimicrobial usage data e.g.NAUSP data

July 2011

Checklist of AMS program elements - for self assessment

June 2011

National point prevalence survey -Data collection tool, reporting facility

Late 2011

2010 Work Program for Committee

Activity Timeline

On line training module on antimicrobial prescribing (with NPS)

1st module Dec 2011

AMS Indicators – included in revised QUM indicator set

Late 2011

Expand Commission’s AMS website–Powerpoint presentation on AMS–Monitoring and measuring tools (include PPS tool) –Link to NAUSP site

July 20112011/2012

April 2011

AMS Webpage

•AMS in Australian Hospitals •Report of 2008 forum and 2011forum (May 2011)

•Presentations on AMS•Resources

• Examples of policies, educational materials etc

• National and organisational AMS websiteswww.safetyandquality.gov.au

Resources

Review and feedback

http://www.safetyandquality.gov.au/internet/safety/publishing.nsf/Content/PriorityProgram-05_ISBAR

National Safety and Quality Standards

Clinical leaders and senior managers of a health service organisation put in place systems for the prevention and management of healthcare associated infection and communicate these to all staff to achieve appropriate outcomes. Clinicians and other staff implement healthcare associated systems. Criterion D. Antimicrobial stewardship Quality antimicrobial prescribing is a strategic goal and an objective of the clinical governance system.

HAI Standard

HAI: D Antimicrobial Stewardship

HAI:D will be achieved by:• Developing,

implementing and regularly reviewing the effectiveness of the antimicrobial management system.

HAI: D MeasureEvidence of:• an antimicrobial

management system• access to Therapeutic

Guidelines:Antibiotic• monitoring of

antibiotic usage, infections with resistant organisms

• MJA article 2010– use of antimicrobial

(NAUSP) data• Windows

– Chapter on AMS 2009– Chapter on AMR 2010

• Discussions with NPS– Practitioner program– Consumer education

Other Activities

• Recommendations to Health Ministers July 2011– AMS publication– Strategy for implementing AMS

• Complete work plan

• Lead and co-ordinate stewardship nationally

Next steps