How to Start an Antimicrobial Stewardship Program

In Conjunction with AzHHA’s Safe and Sound Patient Safety Initiative

Patty Gray RN, CIC & Bill Wightkin, Pharm D, R.Ph

Learning Objectives

After listening to the presentation, viewing Power Point slides and participating in a question and answer session, the participant will:

A. Be able to list the recommended components of an antibiotic

stewardship program B. Be able to detect antibiotic use improvement

opportunities from the analysis of utilization data C. Be able to explain the barriers for successful implementation of such a program

Presentation Outline

I. Why Develop an Antimicrobial Stewardship Program? A. Infection control nurse’s perspective B. Hospital pharmacist’s perspective II. Recommended Components of a Program III. Scottsdale Healthcare’s Program A. Short history B. Committee membership and leadership C. Goals of the committee D. Activities-to-date E. Results so far F. Opportunities for improvement G. Next steps IV. Audience questions and answers

Why Develop an Antimicrobial Stewardship Program

From an Infection Preventionist Perspective:

Track and Reduce antimicrobial resistance

Encourage appropriate treatment patterns ~ The right antibiotic, for the right duration

Develop a collaborative practice between MDs/LIPs, Pharmacy, Laboratorians and Infection Preventionists’ with best patient outcome in mind

Education Catalyst

Why Develop an Antimicrobial Stewardship Program?

Hospital Pharmacist’s Perspective:

Allows needed FOCUS on a drug class

Need to assure appropriate medication management and safety

Assist with educational efforts

Assist with formulary standardization

Control costs

Antimicrobial Purchases

Yearly Expense

Daptomycin $696,000

Pip/Tazo $585,000

Zyvox $444,000

Primaxin $415,000

Caspofungin $400,000

Levofloxacin $338,000

Invanz $335,000

Tygacil $284,000

Expense of Top 100 Drugs:$17.5 million/yr

Antimicrobials = $5 million/yr

29%

Recommended Components of an Antimicrobial Stewardship Program

Foundation = 2 core, proactive strategies

Prospective audit with intervention and feedback

Formulary restriction and preauthorization

Other Recommended Components of an Antimicrobial Stewardship Program

Standardized order sets and clinical pathways (foster evidence-based prescribing)

Antimicrobial order forms

De-escalation of therapy (Review C&S results; on-going review of therapy)

Dose optimization (right dose for site of infection; renal dose adjustment)

IV to oral dose conversion

Scottsdale Healthcare’s Program: History

Evolution from an Antibiotic Subcommittee of the P&T Committee

Perception of an Antibiotic Restriction and Control Approach

Acknowledgement of Hospital and Community considerations

Need for Administrative and Board Support Mission Development ~ Educational/Cooperative

Focus~ Stewardship University of Kentucky Program- Dr. R. Rapp New Hospital with need for guidelines upon opening

of facility

SHC Program~ Committee Membership and Leadership

Medical Staff- Active participation is critical to success

Includes Chief Medical Officer support, ID , Hospitalists, Intensivists, Pulmonary, ED, Community MDs and others as willing

Pharmacy- Coordinates the efforts of the team, guideline development, education and tracking reports

Infection Prevention & Control- Prevention Strategies, hand hygiene, precautions, medical staff-nursing laison

Microbiology- Data trends, special testing expertise Quality & Organizational Development- Performance

Improvement guidance; meeting guidance

Goals of Committee

Assist providers in appropriate use of antimicrobial therapy with improved patient outcomes

Slow the development of antimicrobial resistance Develop evidence- based appropriate use guidelines Educate providers and staff regarding guidelines Track resistance patterns and report back to medical

and hospital staff Report committee progress and outcomes to P&T,

and Executive Committees

Activities to Date

Developed guidelines for 4 antimicrobials

Day 7 of therapy reminder to chart

Day 10 of therapy phone call from pharmacy ID resident

Drug utilization evaluation (DUE)

Results so far (2 months of data)

Drug % of patients with an

Infectious Disease Physician

Consultation

Criteria Non-Conformance

Rate

Caspofungin 100% (30 patients) 23% (no de-escalation to

another agent withCandida albicans)

Daptomycin 93% (41 patients) 24% (no trial of vancomycin for skin infections)

Linezolid 82% (33 patients) 64%

Tigecycline 79% (34 patients) 68%

Opportunities for Improvement

DUE reveals significant non-conformance to adopted guidelines

Are guidelines appropriate?

It does not appear that ID physicians are sufficiently engaged in the stewardship activities

Stewardship Foundation = 2 core, proactive strategies Is our process ROBUST (interventions after 7-10

days)??

Barriers & Opportunities for Improvement

Cultural Perceptions- Medicine’s Heirarchy

Integration of Team Approach and Evidenced Based Practice into culture

Continued Involvement of Hospitalists & Community MDs

Infectious Disease MDs support, agreement & use of guidelines

Turnover of Pharmacy Leadership

Ongoing Administrative Support

Next Steps

1. Re-evaluate physician leadership

2. Formulary evaluation: caspofungin vs. micafungin vs. anidulafungin

3. Transition from faculty ID pharmacist leadership to SHC pharmacy clinical staff

4. Explore expansion of pharmacist clinical duties to include

antimicrobial stewardship responsibilities

5. Improvement of the 2 core proactive strategies

Next Steps

ASK WHY…...determine and address prime causative factors that have resulted in:

1. Antibiotic overuse 2. Sub-optimal antibiotic selection 3. Too long duration of therapy4. Lack of de-escalation to more appropriate agents5. Slow switch to oral therapy

Marketing pressure?Education-Training-Competency?Workload issues with poor attention to detail?Insufficient pharmacy involvement?

http://id2.wustl.edu/~casabar/downloads/antibioticstewardship08.pdf

References

Dellit TH, Owens RC, McGowan JE, et al. Infectious Diseases Society of America

and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial

stewardship. Clin Infect Dis. 44 (1): 159-177, 2007.

McQuillen DP, Petrak RM, Wasserman RB, et al. The value of infectious disease specialists: Non-patient care activities. Clin Infect Dis. 47:1051-1063, 2008.

Spellberg B, Guidos R, Gilbert D, et al. The epidemic of antibiotic-resistant

infections: A call to action for the medical community from the Infectious

Diseases Society of America. Clin Infect Dis. 46 (2): 155-164, 2008.

Antimicrobial Stewardship

QUESTIONS?