Transcript Antimicrobial stewardship - Wichita State University

Antimicrobial
Stewardship
Carrie Poteete MLS(ASCP)cm
Objectives
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Explain the problem
Define Antimicrobial Stewardship
Discuss PCAST
Explain the presidential executive order
Discuss what other states are doing
Discuss what is currently being done in Kansas
Threat Report-Current state of affairs
• Issued September 16, 2013 using data from
at least 10 states
• Threats were assessed according to seven
factors related to resistant infections
• Health impact
• Economic impact
• How common is the infection
• 10-year projection of how common it will
become
• How easily it spreads
• Availability of effective antibiotics
• Barriers to prevention
http://www.cdc.gov/drugresistance/threat-report-2013
Urgent Threat
• Clostridium difficile
• Carbapenem-resistant
Enterobacteriaceae
(CRE)
• Drug-resistant
Neisseria gonorrhoeae
http://blog.labplanet.com/2012/01/27/antimicrobial-sensitivity-testing/
http://www.sciencetimes.com/articles/688/20141012/treating-c-diff-infection-with-oral-frozen-encapsulated-fecal-material.htm
Serious Threats
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Multidrug-resistant Acinetobacter
Drug-resistant Campylobacter
Fluconazole-resistant Candida (a fungus)
Extended spectrum β-lactamase producing Enterobacteriaceae
(ESBLs)
Vancomycin-resistant Enterococcus (VRE)
Multidrug-resistant Pseudomonas aeruginosa
Drug-resistant Non-typhoidal Salmonella
Drug-resistant Salmonella Typhi
Drug-resistant Shigella
Methicillin-resistant Staphylococcus aureus (MRSA)
Drug-resistant Streptococcus pneumoniae
Drug-resistant tuberculosis
http://www.webmd.com/skin-problems-and-treatments/understanding-mrsa
Concerning Threats
• Vancomycin-resistant
Staphylococcus aureus (VRSA)
• Erythromycin-resistant Group A
Streptococcus
• Clindamycin-resistant Group B
Streptococcus
www.examiner.com
Threat report-Key points
2 million
23,000
250,000
14,000
$20 billion
$35 billion
50%
http://www.clipartbest.com/
What is stewardship?
• “Antimicrobial stewardship refers to coordinated interventions
designed to improve and measure the appropriate use of
antimicrobials by promoting the selection of the optimal
antimicrobial drug regimen, dose, duration of therapy, and route
of administration.”
• “Antimicrobial stewards seek to achieve optimal clinical outcomes
related to antimicrobial use, minimize toxicity and other adverse
events, reduce the costs of health care for infections, and limit
the selection for antimicrobial resistant strains” –IDSA
http://www.idsociety.org/Index.aspx
Elements of Stewardship
• Prospective
audits
• Interventions
• Feedback
PRESIDENT’S COUNCIL OF ADVISORS ON SCIENCE AND
TECHNOLOGY – (PCAST)
GOALS (July, 2014)
Welcome to the President's Council of Advisors on Science and Technology, known as PCAST.
https://www.whitehouse.gov/administration/eop/ostp/pcast
The PCAST report focuses are 3 main area:
1) Improving surveillance of the resistant bacteria
2) Increasing longevity of current antibiotics
3) Increasing the rate in which new antibiotics and other inventions
are discovered and delivered
http://antibiotic-action.com/aa-resources/
Second Recommendation
Effective surveillance and response for
antibiotic resistance
• Strengthen state and local public health
infrastructure
• Increase funding
• Establish a national surveillance system for
resistance based on genomic analysis
http://www.philly.com/philly/blogs/public_health/Taxes--thats-right-new-taxes--for-public-health.html
Sixth Recommendation
Improve stewardship of existing antibiotics in
the health care setting
• CMS should put reimbursement incentives
into place
• Government funding requirements to drive
stewardship
• Government should lead by example
http://www.va.gov/
https://www.cms.gov/
Barriers to Stewardship
Higher priority
clinical initiatives
Staffing concerns
Insufficient funding
https://bobsnewheart.wordpress.com/2014/10/31/the-greatest-threat-to-your-health/
Presidential Executive Order
https://www.whitehouse.gov/about/inside-white-house
Goal 1
Slow the Emergence of
Resistance Bacteria and
Prevent the Spread of
Resistant Infections
http://howshealth.com/antibiotic-resistance
Goal 1
• Implement public health
programs for reporting
resistance
• Foster stewardship
programs in all
healthcare settings as
well as the community
http://www.microbioncorp.com/who-report-reveals-global-antimicrobial-resistance-warning/
Goal 1
• Education to inform
clinicians and the public
about stewardship
• Support public health
departments in
establishing
antimicrobial
stewardship programs
Goal 1
• Expand collaborative efforts
annual reporting
• Implement annual reporting
of antibiotic use
• Develop and pilot new
interventions
http://www.ltlmagazine.com/article/groups-commit-responsible-antibiotic-use
Goal 2
Strengthen
national
one-health
surveillance
efforts to
combat
resistance
http://epi.ufl.edu/onehealth/news/
Goal 2
• Create regional public
health lab network
• Develop the Detect Network
of AR Regional laboratories
http://www.google.com/imgres?imgurl=https://lh3.googleusercontent.com/-tqEj5Lo0LdE/AAAAAAAAAAI/AAAAAAAAAAA/K1b6-_tt9q8/s0-c-k-nons/photo.jpg&imgrefurl=https://plus.google.com/u/0/103851806558654155503&h=500&w=500&tbnid=-621rCOxqyHHkM:&tbnh=160&tbnw=160&usg=__BqncLM8CvAWhac3hhLdBfr15OQ=&docid=k4p7Z5aA8YOO7M&itg=1
Goal 2
• Formally recognize the Multi-Resistant
Organism Repository and Surveillance Network
http://wrair-www.army.mil
Goal 2
• Link data on susceptibility testing to make it
available to local, state, and federal health
authorities
• Submit measures to the National Quality Forum
How do we know stewardship works?
Decrease resistant infections:
Tertiary care teaching hospital in
the surgical and trauma ICU,
Charlottsville, VA, USA
Instituted an abx cycling program
Significant reductions in the incidence
of:
• Antibiotic-resistant GPC infections
7.8/100 vs. 14.6/100
• Antibiotic-resistant GNR infections
2.5/100 vs. 7.7/100
• Mortality associated with infection
2.9 deaths/100 vs. 9.6 deaths/100
500-bed university affiliated
community hospital, Queens, NY,
USA
Adopted a Restriction based
program restricting routine
cephalosporin use and requiring
primary team to seek ID approval
for use
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80.1% reduction in hospital-wide
cephalosporin use
44% reduction in incidence of
ceftazidime-resistant Klebsiella
infection and colonization
throughout the hospital
70.9% reduction in all intensive care
units
87.5% reduction in SICU
How do we know stewardship works?
Decrease C. difficle infections:
683-bed, secondary/tertiary-care
hospital, Sherbooke, Quebec,
Canada
• Developed guidelines for
decreasing antibiotics use
associated with Clostridium
difficile infections –
• Creation of educational
materials for physicians and
pharmacists.
• Created recommendations to
suggest alternative antibiotics
for treating conditions.
• Recommended shorter
treatment duration for certain
conditions based on IDSA’s
guidelines.
• C. diff incidence decreased
60% between 2003-2004 and
2005-2006,
• Total and targeted antibiotic
consumption decreased 23%
and 54% respectively.
How do we know stewardship works?
Decrease Cost:
545-bed, statesupported, tertiary-care
teaching hospital,
Jackson, MS, USA
Established restrictions on use of 2nd
generation cephalosporins and
aminoglycosides requiring obtaining
pharmacy approval before drug
disbursement
• Second generation cephalosporin use
decreased 52.2%,
• tobramycin decreased by 75.9% while
unrestricted gentamicin increased 229%
• Reduced expenditures on injectable
antibiotics by $193,172.06 during 12 months
following restrictions.
175-bed, tertiary-care
children's hospital,
Baltimore, MD, USA
Implemented Electronic Monitoring
to provide automated clinical
decision support, facilitate approval
and allow real-time communication
with prescribers related to
antibiotics.
• Reduction in $370,069 in projected, annual
cost associated with restricted
antimicrobial use
• 11.6% reduction in doses of restricted
antibiotics over one year.
• User satisfaction improved from 22% to 68%
and from 13% to 69% among prescribers and
pharmacists respectively.
How do we know stewardship works?
Decrease use:
689-bed tertiary
care teaching
hospital, Omaha,
NE, USA
Created an order form for • Increase in patients receiving appropriate
surgical antimicrobial
antibiotics following intervention (84.9% from
prophylaxis
62.3%),
Form use was mandatory
• Significant improvement in appropriate dosing of
but had an "opt out" space
antibiotcs for weight (89.9% from 62.1%),
on it
• Significant increase in appropriate duration of
prophylaxis (89.1% from 77.8%).
• Mean cost of antimicrobial prophylaxis decreased
to $40 per patient from $46 per patient
California
http://cafrino.com/california-online-poker-bill-passes-through-committee/
https://www.google.com/search?q=california+public+health&biw=1477&bih=730&source=lnms&tbm=isch&sa=X&sqi=2&ved=0CAgQ_AUoA2oVChMI95ukqc_MxwIVCdOACh3XIw
ar&dpr=1.3#imgrc=yG7OrxEoNosgYM%3A
Michigan
http://www.mi-marr.org
https://www.google.com/search?q=michigan&biw=1477&bih=730&source=lnms&tbm=isch&sa=X&sqi=2&ved=0CAcQ_AUoAmoVChMIytmfmdH
MxwIVh9KACh2Kvgic#tbm=isch&tbs=rimg%3ACYUZloq2yxYGIjgbHTtzF-BWlmhR5sK_1etjEpXIJXXXzEhixoCiJ4Xf6gBzjyIbIvD-Y8gNgzYKOFT5rujpBnvaCSoSCRsdO3MX4FaWEV8I0x1gH2EBKhIJaFHmwr962MQRmYA7w_1rrm1EqEgmlcglddfMSGBGWVrtYiBCCqioSCbGgKInhd_1qAERUljXMkwmz
cKhIJHOPIhsi8P5gRP6WXT6tVhnMqEgnyA2DNgo4VPhGodnpEVGeGWCoSCWu76OkGe9oJEfxucxPbD7qV&q=michigan&imgrc=hRmWirbLFgayXM%
3A
Oregon
http://www.usa4kids.com/flags/Oregon.html
https://public.health.oregon.gov/PreventionWellness/SafeLiving/AntibioticResistance/Pages/GetAwarePublications.aspx
https://www.google.com/search?q=kansas&biw=1477&bih=730&source=lnms&tbm=isch&sa=X&sqi=2&ved=0CAcQ_AUoAmoVChMIydzQ1tTMxwIVgriACh3jUQyp#tbm=isch&tbs=rimg%3ACYJkZ7wPKUbIjg5XBukublhpkNAsreWSQcFm5DqxxOzwy3CGNqIBP7_14s8O4aOrT2tPyfxoaHQ1xY1uoLY_1zR18XSoSCTlcG6S5uWGmEfm2chNgYFWoKhIJQ0Cyt5ZJBwURcNMGYf_16mm0qEgmbkOrHE7PDLREJ6nt2AZ5EBioSCcIY2ogE_1v_1iEeOEGcqVq2PgKhIJzw7ho6tPa08RD
7crgqb8gR4qEgnJ_1GhodDXFjRGxB7-tDreRmioSCW6gtj_1NHXxdEcah1YetPHhj&q=kansas&imgdii=zw7ho6tPa0_vrM%3A%3Bzw7ho6tPa0_vrM%3A%3BlCCnOvl5Ua6azM%3A&imgrc=zw7ho6tPa0_vrM%3A
http://www.kansas.gov/
http://www.50states.com/flag/ksflag.htm#.VeDJO3BRHF4
Where can Kansas go from here?
Track antibiotic use and
resistance patterns
Establish policies and
guidelines for antibiotic use
Educate and Evaluate
Provide feedback
Thank You!
http://eideard.com/2014/10/10/antibiotics-stewardship-reduces-rate-of-hospital-readmission-for-children/