Transcript Antimicrobial Stewardship and Formulary Management

Multidisciplinary Partnerships to
Reduce Clostridium difficile
Infection: A Success Story
Laura Johnson, MD
Hospital Epidemiologist, Infectious Diseases
Henry Ford Health System
Rachel Chambers, PharmD
Pharmacy Specialist, Antimicrobial Stewardship
Henry Ford Hospital
Objectives
 The burden and severity of Clostridium difficile infection
(CDI) has dramatically increased in recent years
 Multidisciplinary collaboration is key to minimizing CDI in
the health care setting
 This presentation will provide an overview of the key
players and multidisciplinary interventions necessary to
successfully manage and reduce CDI
Clostridium difficile Infection (CDI)
 Bacterial infection of colon resulting in spectrum of disease
from mild diarrhea to severe colitis with sepsis, toxic
megacolon, and even death.
 Spores persist in healthcare environment and are
transmitted by fecal-oral route.
 Hands and Environment
 Antibiotic exposure kills off normal protective gut flora and
C. difficile can grow and produce toxins, resulting in
disease.
Deaths per million population
Yearly Clostridium difficile–related Mortality by Listing on Death
Certificates, United States, 1999–2004.
Redelings MD, et al. Emerg Infect Dis. 2007;13:1417-1419
Increased and Severe CDI at HFH
 2007/8: Patients noted to have severe CDI, some requiring colectomy
 1988 to 2007: 8 colectomies
 March to May 2008: 7 colectomies
 Surveillance of CDI Initiated
Rate per 10,000 Patient Days
HFH Nosocomial C. diff Rates 2008-2009
40.0
30.0
20.0
10.0
0.0
Rate
JAN FEB MA APR MA JUN JUL AU SEP OCT NO DEC JAN Feb
22.6 14.8 21.5 31.3 24.7 19.3 14.7 17.3 16.8 17.2 26.3 24.0 23.3 21.7
Benchmark 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00
Investigation of Problem
 Infection Prevention started surveillance program
 Deep dive into severe CDI cases
 Collaboration of Infection Prevention, Pharmacy, Clinical
Quality and Safety Office, and Care Providers
Guidelines for C. difficile Prevention and Control
CDC Prevention Strategies: Core
Contact Precautions for duration of diarrhea
Hand hygiene in compliance with CDC/WHO
Cleaning and disinfection of equipment and environment
Laboratory-based alert system for immediate notification of
positive test results
 Educate about CDI: HCP, housekeeping, administration,
patients, families
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http://www.cdc.gov/ncidod/dhqp/id_CdiffFAQ_HCP.html
Dubberke et al. Infect Control Hosp Epidemiol 2008;29:S81-92.
CDC Prevention Strategies: Supplemental
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Extend use of Contact Precautions beyond duration of diarrhea
Presumptive isolation for symptomatic patients pending
confirmation of CDI
Evaluate and optimize testing for CDI
Implement soap and water for hand hygiene before exiting room of
a patient with CDI
Implement universal glove use on units with high CDI rates
Use sodium hypochlorite (bleach) – containing agents for
environmental cleaning
Implement an antimicrobial stewardship program
http://www.cdc.gov/ncidod/dhqp/id_CdiffFAQ_HCP.html
Implementing CDC Guidelines
Requires a “SWOT” Team
 Clear guidelines to prevent and control C. difficile
 The challenge
 Implementation
 Sustainability
 C. difficile Task Force created
 To identify and address our “strengths, weakness, opportunities and
threats”
 To reach multiple disciplines in hospital and facilitate buy-in
 To change practice and culture related to prevention and control
practices
C. difficile Task Force
 Infection prevention practitioners
 Providers: infectious disease, medicine, surgery, intensive care,
gastroenterology
 Nursing (general practice, intensive care, front line and educators)
 Pharmacy
 Laboratory
 Environmental services
 Facilities/plant operations
 Office of clinical quality and safety
 Reporting to hospital leaders
Examples of Collaboration

Infection Prevention and Environmental Services
 Weekly rounds (with “bug meter”)
 Developed enhanced bleach cleaning protocols
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Laboratory and Infection Prevention
 Improved turn around time for lab result
 Developed process for daily notification of results
 Enhanced lab testing with better sensitivity and specificity
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Infection Prevention and ICU Nursing Team
 Developed protocol for RN-Initiated testing for CDI
 “Caboodles” for supplies to decrease contamination of supplies in room
 Eventually, protocol for “fecal transplant” for treatment of difficult cases
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Transportation and Nursing
 Identified need to keep chart clean during transport – cover chart in plastic bag
during transportation
Examples of Collaboration
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Inter-Nursing Collaboration
 Sticker on chart in addition to door sign for improved communication
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Facilities, Nursing, Infection Prevention
 Identified areas with limited sinks and installed sinks on multiple floors
 Installed wall caddies for easy access to PPE
 Stickers on Alcohol Hand Rub canisters
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Admissions Office, Nursing, Infection Prevention
 Extended Precautions till discharge
 Cohorting patients during room shortages
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Surgeons and Infectious Disease Team
 Implemented trial of probiotic yogurt in ICU
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Infectious Disease Fellows and Pharmacy
 Reviewed management of CDI cases daily with interventions as necessary
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Enhancement of Antimicrobial Stewardship Program – A major collaboration with pharmacy
colleagues…
The Case for Antimicrobial Stewardship
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As much as 50% of antibiotic
use is inappropriate
Inappropriate antibiotic use
associated with poor patient
outcomes, resistance
development, increased
health-care costs
Declining antibiotic pipeline in
recent years
New Antibiotic Approvals
16
14
12
10
8
6
4
2
0
1983-1987
1988-1992
1993-1997
1998-2003
2004-2007
Modified from Spellberg B et al. Clin Infect Dis;
2008;46:155-64
Dellitt TH et al. Clin Infect Dis 2007;44:159-77.
Dellitt TH et al. Clin Infect Dis 2007;44:159-77.
Highlights of the Stewardship Guidelines
 Multidisciplinary collaboration: stewardship team, infection
control, Pharmacy &Therapeutics
 Support from hospital leadership and medical staff
 Appropriate compensation (ideally through offices of quality/patient
safety)
 Administrative support to track outcomes
 2 core strategies:
 Prospective audit with intervention & feedback
 Formulary restriction with preauthorization
Dellitt TH et al. Clin Infect Dis 2007;44:159-77.
Antimicrobial Stewardship Strategies
Component
IDSA/ SHEA Guideline
Strength of Evidence
Implemented at
Henry Ford Hospital
Formulary restriction with audit
and feedback
AI

Education
AIII, BII

Guidelines, pathways
AI, AIII
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Antimicrobial cycling
CII
No
Antimicrobial order form
BII
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Combination therapy
CII
Not routine
De-escalation
AII

Dose optimization
AII

IV to PO Conversion
AII

Dellitt TH et al. Clin Infect Dis 2007;44:159-77.
Henry Ford Hospital (HFH) Antimicrobial
Stewardship Program (ASP)
 What is it?
 A comprehensive system of health-care providers, pathways,
guidelines, order sets, and informatics designed to optimize
antimicrobial utilization
 Mission statement
 To improve patient outcomes through optimization of
antimicrobial therapy and support the education of health-care
providers in appropriate antimicrobial use
7 Strategies for a Successful Stewardship Program
Cooke FJ, et al. Clinical Governance 2004
Key Element
Local Action at HFH
Integration into Pre-Existing
Structures
 Quality and safety coordination of
multidisciplinary CDI task force
Strong Leadership
 Pharmacy and antimicrobial
subcommittee ownership for
antimicrobial stewardship
Dedicated Individuals
Responsible for Antibiotic Use
Harnessing Existing Resources
to Deliver Change
Obtaining Local Data on
Prescribing and Resistance
Communication
Education and Training
 Recommendations implemented by
antimicrobial subcommittee of
Pharmacy & Therapeutics
7 Strategies for a Successful Stewardship Program
Cooke FJ, et al. Clinical Governance 2004
Key Element
Local Action at HFH
Integration into Pre-Existing
Structures
Strong Leadership
 Quality and Safety coordination
Dedicated Individuals
Responsible for Antibiotic Use
 Strong multidisciplinary involvement
with Chief of Infectious Disease and
Gastroenterology directly involved
Harnessing Existing Resources
to Deliver Change
 Support from Director of Pharmacy
Services, Chief Medical Officer,
Hospital Administration
Obtaining Local Data on
Prescribing and Resistance
Communication
Education and Training
7 Strategies for a Successful Stewardship Program
Cooke FJ, et al. Clinical Governance 2004
Key Element
Local Action at HFH
Integration into Pre-Existing
Structures
Strong Leadership
Dedicated Individuals
Responsible for Antibiotic Use
Harnessing Existing Resources
to Deliver Change
Obtaining Local Data on
Prescribing and Resistance
Communication
Education and Training
 Antimicrobial Subcommittee
 Stewardship pharmacist
 Stewardship rounds with Chief of
Infectious Diseases
 Infectious Diseases pharmacy
residency program added
7 Strategies for a Successful Stewardship Program
Cooke FJ, et al. Clinical Governance 2004
Key Element
Local Action at HFH
Integration into Pre-Existing
Structures
Strong Leadership
Dedicated Individuals
Responsible for Antibiotic Use
Harnessing Existing Resources
to Deliver Change
Obtaining Local Data on
Prescribing and Resistance
Communication
Education and Training
 Placing a higher priority on the
“stewardship agenda” within existing
clinical pharmacy and infectious
diseases practice model
 Pharmacy resident project
dedicated to validation of CDI
management algorithm
 Infectious diseases fellows
performed daily review of C.
difficile infected patients
7 Strategies for a Successful Stewardship Program
Cooke FJ, et al. Clinical Governance 2004
Key Element
Local Action at HFH
Integration into Pre-Existing
Structures
Strong Leadership
Dedicated Individuals
Responsible for Antibiotic Use
Harnessing Existing Resources
to Deliver Change
Obtaining Local Data on
Prescribing and Resistance
Communication
Education and Training
 Deep dive into C. difficile cases to
identify “problem” antibiotics
 Stewardship program efficiency
improved with implementation of
Theradoc® decision support
software
7 Strategies for a Successful Stewardship Program
Cooke FJ, et al. Clinical Governance 2004
Key Element
Local Action at HFH
Integration into Pre-Existing
Structures
Strong Leadership
Dedicated Individuals
Responsible for Antibiotic Use
Harnessing Existing Resources
to Deliver Change
Obtaining Local Data on
Prescribing and Resistance
Communication
Education and Training
 Multidisciplinary task force members
responsible for disseminating change
to their department/ discipline
 Presentations at grand rounds and
departmental meetings
 Policies and guidelines
communicated in hard copy and on
Intranet
 National presentations and posters
to describe the work (e.g. C. difficile
management algorithm presented at
ICAAC 2009)
Antimicrobial Stewardship Website:
Guidelines and Education
C. difficile Management Pathway
Adapted from: Drugs 2007; 67(4):487-502 and Infection Cont Hosp Epidemiol 2010; 31:431-455.
Compliance with institutional pathway was
associated with improved outcome
Treatment success was defined as clinical resolution of CDI by day 14 or
end of treatment (EOT) and the absence of complications or relapse
Richardson C et al, abstract 423, IDSA 2009, Philadelphia, PA
7 Strategies for a Successful Stewardship Program
Cooke FJ, et al. Clinical Governance 2004
Key Element
Local Action at HFH
Integration into Pre-Existing
Structures
 Priorities are set by antimicrobial
subcommittee, identification of key
messages for educational initiatives
Strong Leadership
 Continuous improvement sought:
Dedicated Individuals
Responsible for Antibiotic Use
• Larger role for ID pharmacist and
stewardship pharmacist
Harnessing Existing Resources
to Deliver Change
• More multidisciplinary education,
ensure training is at an
appropriate level for each group
Obtaining Local Data on
Prescribing and Resistance
• Increase involvement of ID
fellows, hospital epidemiology,
microbiology
Communication
Education and Training
Follow Through and Accountability
 Guidelines are well established and often many eager participants –
but challenge is to move process forward
 Consistent data/messages to hospital leadership
 Problem identified as a priority to leaders
 Capital and resources
 Structure to support accountability
 Office of Clinical Quality and Safety
 Leaders and executive committees maintain accountability
Task Force Results
Rate per 10,000 Patient Days
HFH Nosocomial C. diff Rates 2009-2011
30.0
25.0
20.0
15.0
10.0
5.0
0.0
Rate
Jan
Jan
Jan
Feb M ar A pr M ay Jun Jul A ug Sep Oct No v Dec
Feb M ar A pr M ay Jun July A ug Sep Oct No v Dec
Feb M ar A pr M ay Jun Jul A ug Sep
'09
'10
'11
23.3 21.7 26.8 27.5 16.0
6.7 13.0
8.7 10.5
7.3
7.5 10.80 8.2 5.89 5.6
9.7
6.2
8.0
8.8
7.4
8.9 10.4
7.3
7.1
6.9
4.7
3.4
3.2
3.4
3.6
5.8
4.4
4.9
B enchmk 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00 7.00
Summary
 Implementing improvement projects with sustained results
requires:
 Thorough investigation of problem/issue
 Communication to key leaders and front line staff
 Multidisciplinary team approach
 Process to hold key players accountable with support
from hospital leaders