Transcript Diapositiva 1

37 ° Congresso Nazionale ANMDO
Bologna, 8-11 giugno 2011
Il rischio infettivo
Controllo delle farmaco-resistenze
Pierluigi Viale
Clinica di Malattie Infettive
Policlinico S. Orsola – Malpighi Bologna
The Vanco-MIC creep of S. aureus
The stabilized ESBL endemia
The troubling outbreaks of KPC
The ominous epidemiology of MDR Acinetobacter
The long walk of MDR P. aeruginosa
Antibiotic resistance is a well recognized problem facing
modern medicine and it is undeniable that in the last few
years, levels of resistance have reached a tipping point
The vicious circle of antibiotic resistance
Environment control
HCWs behavior
ATB stewardship
Bed side ATB choice
Bed site ATB use
ATB stewardship
Antimicrobial Stewardship: DEFINITIONS
Infectious Diseases Society of America and the Society for Healthcare
Epidemiology of America Guidelines for Developing an Institutional Program to
Enhance Antimicrobial Stewardship
Dellit TH et al, Clin Infect Dis 2007; 44:159–77
An activity that optimizes antimicrobial management and
includes selection, dosing, route and duration of
antimicrobial therapy.
A marriage of infection control (Epidemiologist) and antimicrobial
management (Infectious Diseases specialist) finalized to share the principles
of the optimized treatment between the bench to bed side point of view
and the hospital-wide vision
“The desire to ingest medicines is one of
the principal features which distinguish man
from the animals”
Osler W. Aequanimitas, 1920
“To Prescribe an antibiotic is easier and faster than think
about its usefulness”
Anonymous 2010
A marriage of infection control (Epidemiologist) and antimicrobial
management (Infectious Diseases specialist) finalized to share the
principles of the optimized treatment between the bench to bed side
point of view and the hospital-wide vision
MINIMIZING UNINTENDED CONSEQUENCES OF
ANTIMICROBIAL USE, INCLUDING TOXICITY, THE
SELECTION OF PATHOGENIC ORGANISMS AND THE
EMERGENCE OF RESISTANCE.
TO REDUCE HEALTH CARE COSTS WITHOUT
ADVERSELY IMPACTING QUALITY OF CARE.
A marriage of infection control (Epidemiologist) and antimicrobial
management (Infectious Diseases specialist) finalized to share the
principles of the optimized treatment between the bench to bed side
point of view and the hospital-wide vision
A CORRECT ANTIMICROBIAL THERAPY IS
MANDATORY IN ALL THESE PATIENTS TO
GUARANTEE THE BEST CLINICAL OUTCOME
A NEW DEAL IN ANTIMICROBIALS MANGEMENT ?
WHAT DOES IT MEAN
“CORRECT ANTIBIOTIC THERAPY”?
Viale P & Pea F Crit Care Med 2006
The microorganism point of view
- A GOOD MICROBIOLOGICAL / EPIDEMIOLOGICAL CHOICE
The drug point of view
- A CORRECT PHARMACOKINETICAL CHOICE and ADMINISTRATION
liphophilic vs hydrophilic drugs
time dependent vs concentration dependent drugs
The patient point of view
- A TARGETED PHYSIOPHATOLOGICAL DAILY SCHEDULA
illness severity grading
physio-pathological conditions affecting distribution
Infectious Diseases Society of America and the Society for Healthcare
Epidemiology of America Guidelines for Developing an Institutional Program to
Enhance Antimicrobial Stewardship
Dellit TH et al, Clin Infect Dis 2007; 44:159–77
A comprehensive evidence-based stewardship program to combat
antimicrobial resistance includes elements chosen from several
recommendations based on local antimicrobial use and resistance problems
and on available resources that may differ, depending on the size of the
institution or clinical setting.
Antibiotic stewardship: overcoming implementation barriers
Bala AM and Gould IM Curr Op Infect Dis 2011;24
Antimicrobial stewardship needs high-level executive commitment.
Infection control and antimicrobial stewardship teams need to work
closely together
Antibiotic care bundles should be implemented.
Antimicrobial stewardship must be seen as part of patient care and not
a management-led cost-saving exercise
Antimicrobial de-escalation has been largely ignored as an important
operational component and should earn its rightful place alongside
guidelines and clinical pathways.
Infectious Diseases Society of America and the Society for Healthcare
Epidemiology of America Guidelines for Developing an Institutional Program to
Enhance Antimicrobial Stewardship
Dellit TH et al, Clin Infect Dis 2007; 44:159–77
6. There are 2 core strategies, both proactive, that provide the foundation for an
antimicrobial stewardship program. These strategies are not mutually exclusive.
A. Prospective audit with intervention and feedback. Prospective audit of
antimicrobial use with direct interaction and feedback to the prescriber,
performed by either an infectious diseases physician or a clinical pharmacist with
infectious diseases training, can result in reduced inappropriate use of
antimicrobials (A-I).
B. Formulary restriction and preauthorization. Formulary restriction and
preauthorization requirements can lead to immediate and significant reductions in
antimicrobial use and cost (A-II) and may be beneficial as part of a multifaceted
response to a nosocomial outbreak of infection (B-II). The use of preauthorization
requirements as a means of controlling antimicrobial resistance is less clear,
because a long-term beneficial impact on resistance has not been established, and
in some circumstances, use may simply shift to an alternative agent with resulting
increased resistance (B-II). In institutions that use preauthorization to limit the
use of selected antimicrobials, monitoring overall trends in antimicrobial use is
necessary to assess and respond to such shifts in use (B-III).
ANTIMICROBIAL ORDER FORMS.
Antimicrobial order forms can be an effective component of
antimicrobial
stewardship
(B-II)
and
can
facilitate
implementation of practice guidelines.
Class restriction of cephalosporin use to control total cephalosporin
resistance in nosocomial Klebsiella. Rahal JJ, et al. JAMA 1998; 280:1233–7
In response to an increasing incidence of cephalosporin- resistant Klebsiella spp,
a preapproval policy was implemented for cephalosporins.
200
141
150
100
69
50
0
ceph use
caz-R Klebsiella in UTI
imip use
-50
-100
caz-R Klebsiella
-44
-80
-77%
imip-R P.aeruginosa
FROM A ZEALOT VISION OF THE FORMULARY
TOWARD A TRUE USEFUL FORMULARY
- NO RESTRICTED DRUGS
- SHARED INDICATIONS OF PRESCRIPTION BY LOCAL EXPERTS
- GRADING OF THE INDICATIONS TO THE PRESCRIPTION
- GRADING OF THE RESPONSABILITY OF THE PRESCRIPTION
FROM A ZEALOT VISION OF THE FORMULARY
TOWARD A TRUE USEFUL FORMULARY
GRADING OF THE INDICATIONS TO THE PRESCRIPTION
FREE PRESCRIPTION
PRESCRIPTION INSIDE A HOSPITAL PROTOCOL
PAY ATTENTION – CONSIDER ALTERNATIVES
ON ID SPECIALIST PRESCRIPTION
AVOID IT IF POSSIBLE !
GUIDELINES AND CLINICAL PATHWAYS.
Multidisciplinary development of evidence-based practice guidelines
incorporating local microbiology and resistance patterns can
improve antimicrobial utilization (A-I).
Guideline implementation can be facilitated through provider
education and feedback on antimicrobial use and patient outcomes
(A-III).
Epidemiology and outcomes of HCAP: results form a large US database of
culture-positive pneumonia
Koleff M et al., Chest 2005;128:3854-62
Outcomes of patients hospitalized with CAP, HCAP, HAP
Venditti M et al, Ann Intern Med 2009;150:19-26
362 patients hospitalized with pneumonia during two 1-week surveillance periods
61.6% had CAP, 24.9% had HCAP, and 13.5% had HAP
HCAP = HAP
Low incidence of multidrug-resistant organisms in patients with healthcare-associated
pneumonia requiring hospitalization
Garcia-Vidal C et al, Clin Microbiol Infect. 2011 Feb 1
A total of 2245 patients with pneumonia were hospitalized, of whom 577 (25.7%) had HCAP
Group 1: received any intravenous therapy at home; received wound care or
specialized nursing care through a healthcare agency, family, or friends; or had
self-administered intravenous medical therapy in the 30 days before pneumonia
(patients whose only home therapy was oxygen were excluded).
Group 2: attended a hospital or haemodialysis clinic or received intravenous
chemotherapy in the 30 days before pneumonia.
Group 3: admitted to an acute-care hospital for two or more days in the 90 days
before pneumonia.
Group 4: resided in a nursing home or long-term-care facility.
Low incidence of multidrug-resistant organisms in patients with healthcare-associated
pneumonia requiring hospitalization
Garcia-Vidal C et al, Clin Microbiol Infect. 2011 Feb 1
A total of 2245 patients with pneumonia were hospitalized, of whom 577 (25.7%) had HCAP
HCAP = CAP
Impact of guideline-consistent therapy on outcome of patients with HCAP and CAP
Grenier C et al, J Antimicrob Chemother Advance Access published May 17, 2011
Methods: A retrospective cohort study of 3295 adults admitted for pneumonia in an academic
centre of Canada, between 1997 and 2008.
Characteristics of patients with CAP versus HCAP
Impact of guideline-consistent therapy on outcome of patients with HCAP and CAP
Grenier C et al, J Antimicrob Chemother Advance Access published May 17, 2011
Distribution of bacterial pathogens
For CAP cases, compliance
with
guidelines
was
independently associated
with lower mortality and
shorter hospital stay
For HCAP cases, nonconcordance of the initial
empirical
regimen
with
guidelines was not a risk
factor for mortality.
The vicious circle within the hospital-acquired pneumonia and health-care-associated
pneumonia guidelines
Yu V Lancet Infect Dis 2011; 11: 248–52
HCAP = HAP ?
Linezolid
+
Carbapenem
+
Quinolone / Aminoglycosides
Critically ill / ICU admitted
HCAP = CAP ?
Non Critically ill / Medical Ward admitted
Amoxi-clav
+
Macrolide
COMBINATION THERAPY
There are insufficient data to recommend the routine use of
combination therapy to prevent the emergence of resistance (C-II).
Combination therapy does have a role in certain clinical contexts,
including use for empirical therapy for critically ill patients at risk of
infection with multidrug-resistant pathogens, to increase the breadth
of coverage and the likelihood of adequate initial therapy (A-II).
Implementation of guidelines for management of possible multidrug-resistant
pneumonia in intensive care: an observational, multicentre cohort study
Kett DH et al, Lancet Infect Dis 2011; 11: 181–89
A performance-improvement initiative in four
academic medical centres in the USA with
protocol-based
education
and
prospective
observation of outcomes was implemented.
Patients were assessed for severity of illness
and followed up until death, hospital discharge,
or day 28; 303 Patients in ICU, at risk for
MDR pneumonia and treated empirically were
included.
Implementation of guidelines for management of possible multidrug-resistant
pneumonia in intensive care: an observational, multicentre cohort study
Kett DH et al, Lancet Infect Dis 2011; 11: 181–89
Guideline-compliant empirical treatment outcomes for 28-day mortality
Reasons for non-compliance were failure to use a secondary anti-Gram-negative
drug –mainly AG - (154 patients) or, less commonly, failure to use either a
primary anti-Gram negative drug (24 patients) or anti-MRSA drug (24 patients).
A stewardship program about the COMBINATION
USE COMBINATION
routinely against selected microorganisms, clinical conditions and patients
NARROW THE ANTIMICROBIAL SPECTRUM AS SOON AS POSSIBLE
using sensitivity data and clinical outcome
AVOID COMBINATION
using drugs with overlapping spectrum
CHOOSE FOR THE COMBINATION
different antibiotic classes
USING A COMBINATION
don’t reduce the daily dose of singular drugs
CHOOSE FOR COMBINATION
Drugs with the best evidence
AVOID THE ROUTINELY USE OF COMBINATION REGIMENS
based on traditions, compulsivity, poor evidence
EDUCATION
Education is considered to be an essential element of any program
designed to influence prescribing behavior and can provide a foundation
of knowledge that will enhance and increase the acceptance of
stewardship strategies (A-III).
However, education alone, without incorporation of active intervention,
is only marginally effective in changing antimicrobial prescribing
practices and has not demonstrated a sustained impact (B-II).
Would you like to easily improve your antimicrobial stewardship ?
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