Transcript Antibiotic Stewardship - What`s New in Medicine

Antimicrobial
Stewardship:
Why and How
John Lynch, MD, MPH
University of Washington & Harborview Medical Center
Disclosure
Consult for the Washington State
Hospitalization Association on HAIs and
antimicrobial stewardship
“Pitted against
microbial genes, we
have mainly our wits”
- Joshua Lederberg,PhD, 1958
C. difficile infection
50%
Adverse effects
Drug resistance
Increased cost
Less C. difficile
50%
Fewer AEs
Slow down MDRs
Decrease cost
Stages of an Ideal Scenario for Treatment of
Infection
• Initial, broad-spectrum antimicrobial therapy is
selected
• Sensitive means to identify pathogenic organism
are used
• Reliable susceptibility result is rapidly achieved
• Antimicrobial therapy is modified
• Antimicrobial therapy is discontinued
Pseudomonas aeruginosa
Escherichia coli
MOA
ESBL
KPC
NDM-1
Chromoso
me/Plasmid
Plasmid
Plasmid
Plasmid
SPICEM
E.coli,
Klebsiella
Klebsiella,
enterobacteriaceae
Klebsiella,
enterobacteriaceae
1 gen Ceph
R
R
R
R
2 gen Ceph
R
S
R/S
R
3 gen Ceph
R
R
R
R
4 gen Ceph
S
R/S
R
R
Cefotax +
Clav
R
S
R
R
Carbapenem
S
S
R
R
Location
Bugs
AmpC
The Apocalypse Pig….
- First description of a
plasmid-mediated
polymixin resistance
mechanism (MCR-1)
- Found on animal meat
and in human infection
samples
- In December, also
reported in Denmark
Liu, Lancet ID, Nov 2015
The Apocalypse Pig….
- First description of a
plasmid-mediated
polymixin resistance
mechanism (MCR-1)
- Found on animal meat
and in human infection
samples
- In December, also
reported in Denmark
Liu, Lancet ID, Nov 2015
Tip of the Iceberg?
760 Cases of VRE identified between Jan 1997 – Oct 1999
Percent of Cases Identified
100
90
80
70
60
50
40
30
20
10
0
86% undetected
by clinical
specimen alone
Clinical Culture
Surveillance
Surveillance,
then Clinical
Culture
Clin Infect Dis
Goossens, Lancet, 2005
Unnecessary Antibiotic Use
Shaughnessy ICHE 2012
Reasons for Antibiotic Use
Shaughnessy ICHE 2012
Estimated U.S. Burden of Clostridium difficile
Infection (CDI), According to the Location of Stool
Collection and Inpatient Health Care Exposure, 2011.
Lessa FC et al. N Engl J Med 2015;372:825-834.
More numbers on antimicrobial problems…
• 2 million people per year in the US are infected
with bacteria with some level of resistance
• At least 23,000 people die as a direct result
• 250,000 people are hospitalized for Clostridium
difficile infections per year
• Around 14,000 people die due to C. difficile per
year
• Excess costs: ~$20 billion direct + ~$35 billion
indirect per year
CDC Antibiotic Resistance Threats in the United States, 2013
CDC (2008)
• Antibiotics are misused in hospitals
• Antibiotic misuse adversely
impacts both patients and society
• Improving antibiotic use improves
patient outcomes and saves money
• Improving antibiotic use is a public
health imperative
What is Stewardship?
“…the conducting, supervising, or
managing of something, especially, the
careful and responsible management
of something entrusted to one’s care”
“The moral and ethical responsibility
for caretaking on behalf of others”
Dr. John Pauk
Antimicrobial Stewardship
• Timely antimicrobial management
• Appropriate selection of antimicrobials
• Appropriate administration and deescalation of antimicrobials
• Use of expertise and resources at point
of care
• Continuous and transparent monitoring
of antimicrobial use
= right drug, right dose, right time, right duration
Pending CMS Requirement
Antimicrobial Stewardship
Strategies
•Educational/guidelines
•Formulary/restriction
•Review and feedback
•Computer assistance
“Minimum Requirements”
• Creation of a multidisciplinary interprofessional
AS team
• Formulary restriction (?)
• Develop institutional clinical guidelines
• Stewardship interventions to detect and
eliminate unnecessary or inappropriate
antimicrobial use
• Process to measure and monitor antimicrobial
use
• Periodic distribution of facility-specific
antibiogram
Dellit, ICHE 2007
CDC Core Elements
•
•
•
•
•
•
•
Leadership commitment
Accountability
Drug expertise
Action
Tracking
Reporting
Education
Antimicrobial Stewardship in Action
New Drugs
and Vaccines
Improved
Diagnostics
Reduced
Resistance
Reservoirs
Education
Infection Control
Benchmarks
Adapted from Fishman, Am J Med, 2006
The Stewardship Team
We may run the ASP, but everyone who pays for, takes, orders,
reviews, fills, delivers, and administers is an antimicrobial
steward.
Prescribing clinicians
- Follow site specific guidelines where possible or other guidelines
- Differentiate between true MDRO risk and being “really sick”
- De-escalate antibiotics ASAP based on data
- Listen to the team clinical pharmacist
Non-prescribers
- Pharmacists have to be leaders and content experts on antimicrobials,
have to be able to interpret micro data and de-escalate
- Microbiologists need to produce timely results and have to explore newer
technologies with quicker turn around times
- Infection control practitioners should provide quality surveillance data
- Administrators must recognize the value of great pharmacists,
microbiologists, and ICPs, and support their participation in the ASP
Antibiotic Prescribing Behavior
(etiquette)
The APB of healthcare professionals is governed by a set of cultural
rules. Antimicrobial prescribing is performed in an environment
where the behavior of clinical leaders or seniors influences practice of
junior doctors. Senior doctors consider themselves exempt from
following policy and practice within a culture of perceived
autonomous decision making that relies more on personal
knowledge and experience than formal policy. Prescribers identify
with the clinical groups in which they work and adjust their APB
according to the prevailing practice within these groups. A culture of
“noninterference” in the antimicrobial prescribing practice of peers
prevents intervention into prescribing of colleagues. These sets of
cultural rules demonstrate the existence of a “prescribing etiquette,”
which dominates the APB of healthcare professionals. Prescribing
etiquette creates an environment in which professional hierarchy
and clinical groups act as key determinants of APB.
Chirani, Clin Infec Dis, 2013
ASP @ Harborview Medical Center
• 413 bed county hospital
• Teaching hospital for UW
• Level 1 trauma/burn center for
WWAMI
• Beds: 61 psych, 29 rehab, 89 ICU
• >60,000 ER visits/year
HMC AS Program Origin
Where we were…
• 2000 = no program
• 2001 AS introduced as Process Improvement project
• Lots of linezolid and imipenem use, CA-MRSA explosion
• 2003 - one ID physician and one ID pharmacist approved
• Daily review of cases collected by ID pharmacist
• No restrictions on antibiotic use
• Tracking of total antibiotic costs, days of hospitalization,
PICC lines* used, savings vs FTE
• IV to PO conversions
• Joint UWMC, SCCA, HMC P&T Committee
• Development of VAP guidelines
• 2 years of monthly meetings to review finances
HMC AS Program Evolution
Integration with Infection Prevention/QI
• Decision support software (TheraDoc and Amalga)
• Use of surveillance data to focus efforts and for feedback
to clinicians
• Quality improvement and patient safety effort
• Surgical Care Improvement Program/SCOAP
Frontlines
• Stewardship program relies on 2 channels:
• Clinician-to-Clinician
• Pharmacist-to-Pharmacist
• Guideline and order set review
• CPOE
• Service-oriented resource for any antibiotic questions
HMC AS Program Today
• Review of cases reported clinical pharmacists
• bug-drug mismatches
• potential de-escalation interventions
• overlapping antibiotic coverage
• dosing
• IV-to-PO conversion
• Review of surveillance alerts
• Discussion of complex interventions and challenges to
intervention addressed as a team
• Review of antibiogram
• Collection of antibiotic costs
• Guidelines, clinical pathways, CPOE review
• Leadership of ID P&T committee
UW P&T Committee- Dosing
Piperacillin/Tazobactam prolonged infusion
Usual dosing is over 30 minutes every 6 hours
• Studies of prolonged infusion – same dose over
4 hours every 8 hours – support similar
outcomes in critically ill patients
• Cuts daily drug amount by 25%
• Challenges: need a line for infusion 12 hours of
the day so RN education and buy-in is critical
• Savings >$30,000
•
VAP Prevention 2003-2004
VAP Prevention 2004-2010
VAP Pathogens 2003
Microorganism
Early Onset
(N=30)
Late Onset
(N=138)
MSSA
8 (27%)
21 (15%)
Haemophilus
8 (27%)
20 (14%)
Strep pneumoniae
6 (20%)
1 (0.7%)
Alpha heme strep
5 (17%)
20 (14%)
MRSA
3 (10%)
32 (23%)
Acinetobacter
3 (10%)
44 (32%)
Enterobacter
2 (7%)
4 (3%)
Pseudomonas
0 (0%)
13 (9%)
Late VAP- Yes Change!
Discontinuing Routine EVD Prophylaxis
Patients with EVD
2011
2012
Positive CSF Culture
12.8% (45/352)
10.3% (38/369)
Percent with C. difficile
5.4% (19/352)
2.4% (9/369)
2011
2012
C. difficile
Cases
Rate per
1000 ptdays
C. difficile
Cases
Rate per
1000 ptdays
Neurosurgery
Service
20
1.18
10
0.55
NICU
19
1.97
5
0.51
Antibiotic Susceptibility Overview
This chart is intended as an initial guidance, and should not replace clinical judgement
Gram Postive Cocci
VRE
Gram Negative Bacilli
Enterococcus
E. coli,
Proteus
fecalis
MRSA MSSA Streptococci Klebsiella mirabilis
Nafcillin, Dicloxacillin
Penicillin
Amoxicillin
Amoxicillin
Cefazolin, Cephalexin
Pseudomonas
Acinetobacter
CEHMPS
Clindamycin
(above diaphragm)
Metronidazole
(below diaphragm)
Clindamycin
Rifampin
Linezolid,
Daptomycin
Vancomycin, Linezolid, Daptomycin
TMP/SMX
Amp/sulbactam
Amox/clavulan
Piperacillin/
tazobactam
Anaerobes
TMP/SMX
Ciprofloxacin
Levofloxacin
Ciprofloxacin
Levofloxacin
Moxifloxacin
Moxifloxacin
Cefotaxime, Ceftriaxone, Cefuroxime
Ceftazidime
Cefepime
Ampicillin/sulbactam,
Amoxicillin/clavulanate
(only anaerobes above diaphragm)
Amp/sulbactam,
Amox/clavulanate
Piperacillin/
tazobactam
Piperacillin/tazobactam
Meropenem
Imipenem
Imipenem
Ertapenem
Gentamicin
Ertapenem
Gentamicin, Tobramycin, Amikacin
Aztreonam
Aztreonam
CEHMPS = Citrobacter freundii, Enterobacter spp., Hafnia alvei, Morganella spp., Providencia spp., Serratia spp.
CEHMPS may harbor AmpC inducile beta lactamases. Resistance to penicillins and 3rd generation cephalosporins may arise on therapy.
TMP/SMX = trimethoprim/sulfamethoxazole, VRE = vancomycin resistant enterococci
Based on 2015 UW Medicine antibiogram, highlighted if suceptibility >70%
ASPs and Technology
On the Near Horizon….
•Tele-stewardship (UW TASP)
•NHSN AUR reporting
On the Not So Far Horizon….
•Antibiotic indications and time-outs
• Technical (EHRs in transition) and
safety?
•“Gold-standard” prospective audit and
feedback
• Challenging with rotating trainees
• Not enough FTE
•Conflicts with CMS sepsis
requirements?
Thanks to…
Jeannie Chan, PharmD, MPH (HMC)
Tim Dellit, MD (HMC)
Rupali Jain, PharmD (UWMC)
Paul Pottinger, MD (UWMC)
The Antimicrobial Stewardship
Consortium of Washington
([email protected])