Antimicrobial Stewardship

UNSOM- ECHO Antibiotic Stewardship Clinic

Jessica Thompson, PharmD, BCPS (AQ-ID)

Mike Stander, PharmD

Charles Krasner, MD

May 21, 2015

Objectives

Define antimicrobial stewardship (AMS)

Discuss why AMS is necessary

List the components of AMS

Provide examples of AMS

Discuss the role of the UNR ECHO

Antibiotic Stewardship Clinic in your AMS

program

Provide example cases

Antimicrobial stewardship

Simply stated, it is the…

◦ Appropriate use of antimicrobials

Appropriate use of antimicrobials

Goals of AMS

Primary goal

◦ Improve patient outcomes

Secondary goal

◦ Save healthcare dollars without adversely impacting quality of care

CID 2007;44:159-77

Reasons why AMS is necessary

Antimicrobial use in hospitals

Up to 30% of a pharmacy’s budget

consists of antimicrobials

Almost 1 out every 2 inpatients receives

an antimicrobial

◦ 30 to 50% are inappropriate

CID 2007;44:159-77

Antimicrobial resistance

Antimicrobial use is directly related to the

emergence of resistance

◦ Hospital costs of an antimicrobial-resistant

infection

$18,500 to $29,000 per patient

Excess duration of stay of 6.4 to 12.7 days

Attributable mortality of 6.5%

CID 2007;44:159-77

CID 2009;49:1175-84

Antimicrobial development

0

2

4

6

8

10

12

14

16

18

1983 - 1987 1988 - 1992 1993 - 1997 1998 - 2002 2003 - 2007 2008 - 2012

Tota

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of N

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rial

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CID 2011;52;S397-S428

Antimicrobial development

0

2

4

6

8

10

12

14

16

18

1983 - 1987 1988 - 1992 1993 - 1997 1998 - 2002 2003 - 2007 2008 - 2012

Tota

l Num

ber

of N

ew A

ntib

acte

rial

Age

nts MRSA

VRE

MDR Pseudomonas

VISA

LZD-R S aureus

KPC

VRSA

MBL

CID 2011;52;S397-S428

Martin, 45th ASHP MCM

Nosocomial in fections

Antibiotic use is a significant risk factor for

nosocomial infections

◦ Clostridium difficile diarrhea (CDAD)

Increasing incidence and mortality

$9,400 to $11,200 excess cost per case

◦ Invasive candidiasis

Attributable mortality is 15 to 25%

$40,000 per case CID 2007;44:159-77

Clin Microbiol Infect 2012;18:282-9

CID 2009;48:503-35

Drug related adverse outcomes

In 2008, 1.9 million inpatient stays were

secondary to a drug related adverse

outcome (4.7% of all stays)

9.4% of all drug related adverse outcomes

were caused by antimicrobials

HCUP Statistical Brief #109 April 2011

Stewardship to the rescue!

AMS outcomes

Better cure rates/decrease failure rates

Decrease length of stay

Reduce infection-related mortality

Improve rates of resistance

Decrease nosocomial infections

Decrease antimicrobial usage by 22 to

36%

Significant drug cost savings

CID 2007;44:159-77

http://www.cdc.gov/getsmart/healthcare

Components of AMS

In an ideal world…

Stewardship team

Infectious diseases physician

Clinical pharmacist preferably with

infectious diseases training

Clinical microbiologist

Information system specialist

Infection control

Hospital epidemiology

CID 2007;44:159-77

Support and collaboration

The AMS team must work closely with the

infection control committee and pharmacy

and therapeutics committee

Support and collaboration is essential

with

◦ Hospital administration

◦ Medical staff leadership

◦ Local providers

CID 2007;44:159-77

AMS options for everyone else

UNR ECHO antibiotic stewardship

Experienced providers to assist you with

your stewardship needs

◦ ID physician, ID pharmacists, and infection

control/prevention

◦ 12:15 to 1 pm the 3rd Thursday of each

month

Role of ECHO clinic

Each clinic or hospital has different needs

We can help you…

◦ Identify needs specific to YOUR institution

◦ Develop and implement plans for

improvement

Assistance we can provide

IV to PO conversion protocol

Streamline your antibiotic formulary

Empiric antibiotic recommendations

Length of treatment recommendations Order sets and bundles

Batching IV antimicrobials

Automatic stop dates

Additional services

Consult ECHO clinic on patient cases or

infection control issues

◦ Opportunity to present during each clinic

◦ Call anytime if it is a time sensitive issue

Disease state presentations are given at

every ECHO clinic

◦ Topic suggestions are welcomed and encouraged

Examples of typical case scenarios

64 year old woman admitted with sepsis from pyelonephritis. Blood/urine

cultures grow out E. coli. She has been on Zosyn since admit, she is now doing

better after 48 hours in hospital, but not yet ready yet for discharge.

Possible questions for AMS discussion :

Is it ok to switch to a less expensive iv drug like ceftriaxone now? Does she need

intravenous therapy for 2 weeks, or are there oral options available ?

54 year old diabetic patient admitted for fever, chills and an infected foot. Initially

placed on vancomycin and Unasyn. Blood and wound cultures grow on Methicillin

susceptible Staph Aureus (MSSA).

Questions:

Should I now change the antibiotic regimen?

Does he need iv therapy or are oral antibiotics an option?

How do I dose antibiotics if he has kidney problems?

I would like to use ceftriaxone in a 62 year old male with a severe prostate

infection. However, years ago his mom told him penicillin allergy runs in his family

and he should never take it. What should I do?

Summary

Antimicrobial stewardship can have a

positive impact on patient care,

antimicrobial resistance, and hospital

cost

Target areas specific to your institution ECHO clinic can help!

◦ We are here for you, your patients, and your

institution

◦ Our goal is “All Things Infectious!”

Call with questions at any time

Questions?

Jessica Thompson

775-982-2180

Jthompson@renown.org

Michael Stander

775-848-9657

Mstander@renown.org

Charles Krasner

775-830-5770

ckrasner@medicine.nevada.edu