Transcript Antimicrobial stewardship where`s the evidence?

Antimicrobial Stewardship
Forum 2010
Victorian Infectious Diseases Service
Royal Melbourne Hospital
and launch of Guidance MS
Introduction and launch of Guidance MS
Assoc Prof Michael Richards - Head VIDS, RMH
Prof Graham Brown - Director Nossal Institute for Global Health University of Melbourne
Dr Kirsty Buising -VIDS
Keynote lectures
Ms Margaret Duguid - Australian Commission Safety and Quality in Healthcare
Dr Kirsty Buising - VIDS
Mr Senthil Lingaratnam- Peter Maccallum Cancer Centre
Workshop - “Stories from the frontline”
Mr Duncan Mckenzie - Royal Hobart
Dr Nadia Chaves - VIDS
Ms Jenny Kirschner and Mr Trent Lee -The Alfred
Mr Mina Georgy - Eastern Health
Ms Marion Robertson - RMH
comments – Verna Wallroth and Os Cotta
Demonstration and Discussion
Renu Shanmugasundaram, Kirsty Buising, Marion Robertson - Guidance Team RMH
Launch of Guidance MS
June 2010
Dr Kirsty Buising
Launch of Guidance MS
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Website – www.guidancems.org.au
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Demonstration of MS “multi-site”
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New functionality
Website
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Information on Guidance
 Team
 Publications
 Enquiry forms
Privileged member area for:
 sharing of content
 relevant resources
Discussion forum
Guidance MS
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Improved “look and feel”
Multi-site
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Categorization by drug class
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Access to sites can be set to specialized users
Site specific content management
Filter by site for ‘searching approvals’
Auditing by site or combined
Permits larger sites to ‘oversee’ smaller sites
Restricted drugs beyond antimicrobials
Pharmacy alert workflow
Antimicrobial stewardship
where’s the evidence?
Kirsty Buising
Infectious Diseases physician RMH, SVH
RMH Antimicrobial Stewardship Forum
June 2010
Outline
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Antimicrobial Stewardship - why it’s important
The association between antibiotic use & MDR bacteria
 Gram positives
 Gram negatives
 C difficile
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Use of antimicrobial stewardship to manage MDR bacteria
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Strategies for stewardship in hospitals
Antimicrobial stewardship
Strategies to improve antimicrobial use
Needs to address both;
 Individual patient outcomes
Prevent morbidity/ mortality from infection
 Toxicity from drugs
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Public health outcomes
Antimicrobial resistance
 Cost
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Why focus on antimicrobials?
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Lots of people are prescribed antibiotics
In hospital
75% patients receive an antibiotic during admission
 40% patients on a given day are receiving antibiotics
In community
2% population on any given day are on antibiotics
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Huge
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heterogeneity in rates of drug consumption
not explained by patient mix
not reflected by any differences in outcome
seen in ICU/ hospital/ community audits
High rates of inappropriate antibiotic use in
hospitals when audited -25-50%
Causes of inappropriate use
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Inappropriate use is due to:
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Lack of knowledge
Attitudes (risk averse practice /medicolegal)
Ill-defined treatment durations
Poor diagnostics
Insufficient information available
Poor communication
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Lab-bedside
Between clinicians over time
Individual outcomes
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Inappropriate therapy assoc mortality
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Delays to appropriate therapy assoc mortality
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Bacteraemia
 Ibrahim Chest 2000
Kumar Crit Care Med 2006
Inappropriate empiric therapy assoc longer LOS
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Cosgrove CID 2006
Need to get it right first time
Clinicians need information to prescribe optimally
Never compromise individual patient care
Public health outcomes
Antimicrobial resistance is a public health threat
ESBL gram negatives
MRSA
VRE
Clostridium difficile
MDR tb
HIV
Malaria
Cost
5/10 highest cost drugs in hospitals are antimicrobials
Importance for us
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ESBL, MDR gram negs
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MRSA
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Australia led the way
 endemic in hospitals, now cMRSA a concern
VRE
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Major issue SE Asia, Eastern Europe,
Mediterranean
Being imported to Australia
rates rapidly increasing 2009, invasive disease
Clostridium difficile
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first Victorian cases 027 strain 2010
Is antibiotic use is assoc with antibiotic
resistant bacteria?
Linking antibiotic use and resistance
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Ecological studies
 National level
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Scandinavia vs Greece/ France
Individual patient level
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Recent systematic review and metaanalysis
Streptococci
with
antibiotic
resistance
-Community
-Costelloe
-BMJ 2010
Urinary tract
infection
-community
prescriptions
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Costelloe
BMJ 2010
Respiratory
tract
infections
-community
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Costelloe
BMJ 2010
Gram positives
MRSA
Systematic review 76 papers MRSA infection
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strong assoc with prior Ab use OR 1.8,
p<0.001
Odds ratios:FQ 3.0, cephs 2.2, beta lactams
1.9
Tacconelli JAC 2008
Modelling studies
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MRSA rates assoc in time with FQ consumption,
3 gen cephs, macrolides and amox-clav
time lag 1-4 months
Aldeyab JAC 2009
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VRE
 No correlation with vancomycin use
 Has been correlated with broad
spectrum antibiotic use
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Prospective multicentre study
 Italy 12 months
 swabs nose, perineum before and after
antibiotics 864 inpatients
 MRSA, VRE, FQ R PsA
 Acquisition highest if carb exposure, esp DM CRF
Gram negatives
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Case control studies
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Carbapenem & quinolone use assoc MDR Pseudomonas
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Beta lactam use assoc with ESBL E coli
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Lodise ICHE 2007
Ortega JAC 2009
Modelling studies
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Switzerland, Community
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MDR Ecoli assoc prior ceftriaxone & ciprofloxacin use,
lag 3 months
Cipro resistant E coli assoc prior cipro use, lag 1 month
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Vernz ECMID 2010
Linking use and resistance
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Systematic review
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case control studies not robust enough to decide,
limited control for confounders
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MV analysis
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suggested that if you categorized drugs by their
spectrum of activity - better correlation with
resistance than by drug class
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Tacconelli ICHE 2006
MacAdam Int J Antimic Agents 2006
Cross resistance needs to be considered – genetic
elements carry resistance to more than one class
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DAgata ICHE 2006
Clostridium difficile
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Defined as a ‘post antibiotic’ diarrhoea
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Prior association with clindamycin
OR of prior antibiotic use in cases vs control is 8.0
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Dial 2010
Clostridium difficile 027 strain
 30 day mortality 20.3%
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Wilcox UK ECCMID 2010
027 strain C diff is resistant to quinolones
23% of 027 C diff cases received quinolones in the 8
weeks prior to their C difficile episode in UK
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Considerations…..
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Are there ‘Bad’ antibiotics?
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? Fluoroquinolones, carbapenems, cephs
Is it something about these drugs?
Is it just just ‘broader spectrum’ drugs
Is it the duration that is more important
Is it the ‘type of patient’ who gets these drugs
Is there evidence that we can
do anything about it?
Can antibiotic stewardship change
prescribing practices
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Lots of single centre studies
Note: effect of intervention depends on what
that intervention is, and features of the
institution receiving it
Ansari JAC 2003
Can AB stewardship reduce MDR
bacteria?
Lots of single centre studies:
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Vancomycin restriction - reduced VRE
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Third generation cephalosporin restriction - reduced;
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Acinetobacter
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White CID 1997
MDR Klebsiella
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Rahal JAMA 1998
Enterobacter & Pseudomonas
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Quale CID 1996
Bamburger Arch Int Med 1992
Carbapenem restriction - reduced resistant Pseudomonas
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Pakyz AAC 2009
Improved susceptibility of Gram negative bacteria in an intensive care unit
following implementation of a computerised antibiotic decision support
system
M.K.Yong, K.L. Buising, A.C. Cheng, K.A. Thursky JAC 2010 April
2001-2002
Overall antibiotic
consumption in ICU fell 10.5%
Carbapenems 39% p 0.04
Third gen cephs 42% p<0.001
Vancomycin
33% p 0.05
Antimicrobial Stewardship and
Antibiotic resistance
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Cochrane review: 66 studies evaluating
antimicrobial stewardship interventions
ASPs are associated with:
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Better empiric antibiotic selection (77% improved)
Reduced length stay
Better timing drugs
Cost savings
Reduced mortality (!)
Ecologic outcomes
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16 studies had ecologic outcome reported
75% showed improvement (?likely publication bias)
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Davey 2002
Updated Cochrane review due soon
105 studies: 26 RCTs, 60 ITS - studies with
microbial, clinical and economic outcomes
Can antimicrobial stewardship
control Clostridium difficile?
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Single centre studies
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Restriction of cephalosporins assoc with reduced
incidence of C difficile
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Carling ICHE 2003, LaRocco ICHE 2003
“Life without ciprofloxacin”
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Sept 2008 – quinolone ban in their hospital
FQ use fell 59% in 1 year
CDI outbreak contained
ECCMID 2010
Need more information
So, how should we do it
Infection control and antimicrobial
stewardship go ‘hand in hand’
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Infection control
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Prevention - Sterility to prevent initial infection
Transmission - when infections happen stop
spread to other patients
Antimicrobial stewardship
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Prevention - Contain the ‘drivers’ that select
AR pathogens (AB overuse)
Treatment - when infections happen treat them
properly
Key principles: improving antibiotic use
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Avoid unnecessary use
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Prevent infections
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? New tools - PCT, FISH, MALDI-TOF, short lab
turnaround
Restrict formulary
Use approval systems - pre and post prescription
Provide information on bugs/drugs - decision
support
Optimize use
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Limit invasive devices, hand hygiene, vaccination
Address surgical prophylaxis
Improve diagnosis
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don’t treat colonization
review at 24-72hrs, de-escalate
Shorten treatment
Audit and feedback
What strategies have been used?
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Education
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Guidelines
Restriction
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Formulary
Approval
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Drug order forms
Phone approval
Electronic approval
Post prescription review
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Pre prescription
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Antimicrobial Mx team, ID reg, Phramacist
Audit and feedback
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appropriateness, consumption, resistance
Bundle of Interventions
“The missing care bundle: antibiotic
prescribing in hospitals”
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Cooke FJ Int J Antimicrob Agents 2007
Minimum standards: HICSIG
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Indication – choice correct
Allergy considered
Dose appropriate
Microbiology considered
Review date set
Deescalate when possible
The whole program
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Stewardship requires a co-ordinated whole institution
program
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A core quality and safety activity for hospitals
Needs to be sustained
Antimicrobial Stewardship committee
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Not just a tool, Not just a person
Junior/ senior doctors, pharmcists, micro, ID, resp,
Clinical pharmacology, ICU, Quality, IT
Victoria, Tasmania, NSW roll out largest multicentre
intervention
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Collaborations, sharing ideas/ content
International attention…..
Readiness assessments
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IT readiness
Administrative support - executive
Process readiness - plan to sustain
Resources - personnel, time allocation
Skills of personnel
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‘Culture’ of the organization
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Early adopter of innovation
Evidence based practice promoted
Quality focus
Research focus
ID/micro profile vs autonomy of clinicians
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Luu SHEA 2010
Threats to success
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“Shepherding precious resources”
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lack of leadership
not enough staff
antagonistic colleagues
industry influence
competing for funding
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Owens Am J Health Syst Pharm 2009
Issues to tackle outside the
hospital
The community
The French community campaign
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Belgian community campaign
Belgian campaign
MDR bacteria in Nursing homes
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7-10% Nhome residents are colonized with MROs
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ICHE 2000 Nicolle Bentley
Why?
 Transfer from acute hospitals
 Poor functional status
 Understaffing/ poor hygiene
 Open wounds/ faecal incontinence/ invasive
devices
Antibiotic use in Nursing homes
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Prevalence of AB use 5-10% on any given
day
1 course per year in 70% of residents
Inappropriate use: 25-70% of prescriptions
Why?
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Most tx is empiric
Most decisions come from nursing assessments
Most prescriptions occur over the phone
Often treating colonization rather than infection
Excessive durations and excessive spectrum of
cover
Interventions in nursing homes
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Great scope for improvement with simple
strategies
Loeb BMJ 2005
 cluster randomized trial 12 intervn vs 12 without
 UTI education program
 31% reduction in ab use for UTIs,
 no change in death or hospitalisation rate
Morette JADS 2007
 cluster randomization 8 nursing homes
 AB guideline given to doctors
 Their personal use assessed as adherent or not
 Non adherence reduced OR 0.36 (0.18-0.73)
Summary
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Antibiotic resistance is a major public health
problem
Inappropriate antibiotic use is a driver of
antimicrobial resistance
Antimicrobial stewardship (AS) is an effective
intervention
Effective AS requires a multifaceted approach
Hospitals - AS is a key quality and safety issue
Community sector also a challenge