Transcript Why Develop an Antimicrobial Stewardship Program From

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
Expense of Top 100 Drugs:
$17.5 million/yr
Zyvox
$444,000
Antimicrobials = $5 million/yr
Primaxin
$415,000
Caspofungin
$400,000
Levofloxacin
$338,000
Invanz
$335,000
Tygacil
$284,000
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 with
Candida 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.
2.
3.
4.
5.
Antibiotic overuse
Sub-optimal antibiotic selection
Too long duration of therapy
Lack of de-escalation to more appropriate agents
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?