Objectives List the potential benefits of antimicrobial - - PDF document

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Antimicrobial Stewardship in Large Hospital Systems: Programs and Experiences

Brad Laible, Pharm.D., BCPS-AQ ID Professor, Department of Pharmacy Practice, SDSU COP Clinical Pharmacy Specialist Avera McKennan Hospital July 22nd, 2015

Objectives

• List the potential benefits of antimicrobial

stewardship.

• Describe commonly used antimicrobial

stewardship approaches.

• Discuss possible barriers to implementing a

successful antimicrobial stewardship program.

• Explain why some antimicrobial stewardship

approaches are more successful than others.

• Identify opportunities for antimicrobial

stewardship initiatives.

Dellit TH, et al. Clin Infect Dis 2007

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http://www.cdc.gov/getsmart/ healthcare/pdfs/checklist.pdf

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https://www.whitehouse.gov/the- press-office/2015/03/27/fact- sheet-obama-administration- releases-national-action-plan- combat-ant

Antimicrobial Stewardship

• Process of promoting:

– Appropriate antimicrobial(s) – Optimal dose – Optimal duration – Minimize toxicity – Minimize selection of secondary infections (Clostridium difficile) – Minimize conditions for selection of resistant strains

Fishman N. Am J Med 2006 Ohl CA. Clin Infect Dis 2011

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Why Antimicrobial Stewardship?

• Multiple studies indicating antimicrobials

are considered unnecessary or inappropriate in >50% of cases

• Minimal antimicrobial compounds in

development for treatment of resistant bacteria

– Particularly Gram-negative organisms

Dellit TH, et al. Clin Infect Dis 2007

Why Antimicrobial Stewardship?

• Limited data for accomplishing

reduction of:

– Extended-Spectrum Beta-lactamase (ESBL) Gram negatives – Clostridium difficile-associated diarrhea – Vancomycin resistant Enterococci (VRE) – Carbapenem-resistant Enterobacteriaceae (CRE)

• Proven reduction in drug cost

Fishman N. Am J Med 2006 Dellit TH, et al. Clin Infect Dis 2007

Types of Antimicrobial Stewardship

• “Front-end”

– Formulary restriction – Prior approval – Education programs / antibiogram distribution – Guidelines and clinical pathways – Antimicrobial order forms / order sets – Dose optimization protocols / consult services (vancomycin, aminoglycosides)

Dellit TH, et al. Clin Infect Dis 2007

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Types of Antimicrobial Stewardship

• “Back End”

– Streamlining or De-escalation

• Following culture results and patient response

to therapy and narrowing therapy accordingly

• Multiple strategies:

– Comprehensive review – Agents with required review – IV to PO switch

• Most institutions use a hybrid of both

Dellit TH, et al. Clin Infect Dis 2007

Difficulties with Antimicrobial Stewardship

• Physician acceptance
• Must be a multidisciplinary approach

– Most effective with Infectious Disease attending and Clinical Pharmacist as core members

• May require significant resources

– Personnel – Time

Dellit TH, et al. Clin Infect Dis 2007

Avera McKennan Antimicrobial Stewardship Program (ASP)

• Collaborative effort between:

– Avera McKennan Pharmacy – SDSU College of Pharmacy Faculty/Students – Infectious Disease Specialists, PC

• Goal:

– Proper Antimicrobial Stewardship

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Avera ASP: 2004 - 2010

• What did we provide?

– Targeted, but continuous antimicrobial regimen review of one patient care floor – Unsolicited recommendations targeted at improving antimicrobial therapy – Antimicrobial restriction for certain antimicrobials (hospital-wide)

Targeted Patient Population

• Avera McKennan Hospital

– 1 West / 1 West D pod

• Medical/Surgical/Trauma
• 55 beds

Antimicrobial Report (Meditech) Reviewed by Pharmacist and PharmD Students Pharmacist and PharmD Students Meet With Infectious Disease Physician for AMT Rounds Antimicrobial Management Communication (AMC) Completed if Recommendations Made Changes Deemed Urgent: Contact Physician Changes NOT Deemed Urgent: Leave AMC in Progress Notes

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Results

Laible BR, et al. J Pharm Pract 2010

Results Results

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What Happened?

• Picked all of the “low hanging fruit”?
• Utilized one method too much?
• Couldn’t maintain the effort?
• Lack of focus?
• ASP chose go another direction…

Focused Stewardship

• Wong-Beringer, et al. 2009
• ASP with a focus on reducing

fluoroquinolone overuse

• 565 bed, acute care, teaching hospital
• Used multiple methods of stewardship

– Monitoring and reporting of antibiogram data – Audit and feedback – IV to PO conversion – Empiric guidelines – Prescriber education

Results

• 30% decrease in fluoroquinolone utilization as

empiric therapy for P. aeruginosa infections

• 10% improvement in susceptibility of P. aeruginosa

to antipseudomonal agents (both ciprofloxacin and structurally unrelated agents)

• 2-fold reduction in mortality associated with

Pseudomonal infections

• Stable level of fluoroquinolone-resistant E. coli

(~20%)

Wong-Beringer, et al. Pharmacother 2009

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Renewed efforts: Avera ASP Fluoroquinolone Avoidance Project 2011 - Current

• Avera Stewardship Workgroup
• ASP program for entire health-system
• Focus on reduction of fluoroquinolone
• veruse
• Multiple approaches to the effort:

– Provider education – Electronic Order Set Revisions

• Started with Pneumonia

– Decentralized pharmacists providing audit and feedback

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Results so far… Avera ASP: Next steps

• Electronic Order Set Revisions:

– Sepsis – General Surgery – Urinary Tract Infection – Cellulitis – Meningitis

• Stewardship diversification

– Clinical pathways – Enhanced Audit and Feedback – Utilization of available technology

ASP Challenges

• Proving worth
• Maintaining the effort / sustaining

results

• Hospital or System Harmony

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ASP: My Recommendations

• Don’t take on too much

– Formulary management (restrictions if able) – Education and antibiogram distribution – Treatment pathways / order sets – Policies / protocols that empower staff to optimize antimicrobial use and meet CMS requirements

• “Back-end” strategies later
• Monitor impact of your efforts

Questions?