IDSA Practice Guidelines for Antimicrobial Stewardship Programs


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This was presented as a continuing education credit for the attendees of the 17th Annual South Florida Residency Seminar in Miami Florida.

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IDSA Practice Guidelines for Antimicrobial Stewardship Programs

  1. 1. IDSA Practice Guidelines for Antimicrobial Stewardship Programs Dr. Joy A. Awoniyi, PharmD. PGY1 Clinical Pharmacy Practice Resident Miami VA Healthcare System 17th Annual South Florida Residency Seminar Saturday, January 26, 2013 1
  2. 2. Objectives To provide a background on the implementation and utilization of Antimicrobial Stewardship Programs (ASPs) To discuss the role of antimicrobial stewardship in the healthcare setting To recognize the IDSA Guideline recommendations and their impact on pharmacy To describe the role of pharmacists in antimicrobial stewardship To recognize the role of the pharmacist and potential interventions for providing optimal pharmaceutical care while shepherding antimicrobial stewardship for the institution 2
  3. 3. “The microbes are educated to resist penicillin and ahost of penicillin-fast organisms is bred out…In suchcases the thoughtless person playing with penicillin is morally responsible for the death of the man who finally succumbs to infection with the penicillin- resistant organism. I hope this evil can be averted.” Sir Alexander Fleming New York Times June 26, 1945 3
  4. 4. Timeline leading to Antimicrobial Stewardship 1990s1930s • MRSA is observed in• Sulfonamides, penicillin and 1940s 1960s over 53% of isolates streptomycin obtained from became • Staph aureus ICU patients in available • Penicillin resistance to resistance to a US• Harnessing of methicillin surveillance antibacterial Staph aureus emerges is detected system agents for • IDSA/SHEA clinical use published begins “Guidelines for Antimicrobial Resistance in Hospitals” 4
  5. 5. Present-day Issues Multi-drug resistance is a significant issue resulting increased morbidity, mortality, and healthcare costs  In 2010, the World Health Organization recognized antimicrobial resistance as 1 of the 3 greatest threats to human health  50% of antimicrobial use is inappropriate Recent decline in the development and approval of newer antibacterial agents Increase incidence of Clostridium difficile associated diarrhea and emergence of resistance to treatment 5
  6. 6. “Antimicrobial resistance is a global problem, and antimicrobial stewardshipprograms are the global solution.” Pharmacy Practice News August 2012 6
  7. 7. What is Antimicrobial Stewardship? “Coordinated interventions designed to improve and measure the appropriate use of antimicrobial agentsby promoting the selection of the optimal antimicrobial drug regimen including dosing, duration of therapy, and route of administration”The Society for Healthcare Epidemiology of America (SHEA), The Infectious Diseases Society of America (IDSA) and the Pediatric Infectious Diseases Society (PIDS) 7
  8. 8. IDSA/SHEA GUIDELINES FOR DEVELOPING AN INSTITUTIONAL PROGRAM TO ENHANCE ANTIMICROBIAL STEWARDSHIP BACKGROUND CONTENTS Published in 2007  Executive Summary Developed and issued on  Introduction including the behalf of the IDSA and purpose and methods of SHEA guideline development The development  Evidence- based of effective hospital based Recommendations stewardship programs  Members of ASP Team All  Elements of ASPs patients in acute care  Research and Future hospitals Directions 8
  9. 9. Purpose of Antimicrobial Stewardship Programs Goals of Antimicrobial Stewardship Programs (ASPs) To optimize clinical outcomes while minimizing unintended consequences of antimicrobial use To reduce health-care costs without adversely impacting quality of care Benefits of ASPs  Financially self-supporting  Improve patient care  Increases appropriateness of antimicrobial use  Increased clinical cure 9
  10. 10. Six Essential Elements Information Microbiology Technology Lab Monitoring of Supplemental Process and Strategies Outcome Measurement Effective Comprehensive Active Antimicrobial MultidisciplinaryStrategies Stewardship Team Approach 10
  11. 11. 1. Active Strategies Prospective audit of Formulary restriction and preauthorization requirements antimicrobial use for specific agents Should include direct Reduces antimicrobial use and interaction and verbal or costwritten feedback to providers Effectiveness of May be facilitated through preauthorization depends on computer surveillance the authorizing individual Utilize the Pharmacy andShown beneficial in both large Therapeutics Committee or and small hospitals equivalent group 11
  12. 12. 2. Supplemental Strategies Most frequently employed  Development of evidence- intervention based practice guidelines that incorporate local microbiology and Essential to improving resistance patterns prescribing behavior  Facilitation of guidelines Will enhance and increase through education and acceptance of stewardship feedback strategies 12
  13. 13. 2. Supplemental Strategies Cycling refers to scheduled  Decrease antimicrobial consumption removal and substitution of a specific antibiotic or  Aid in utilization of developed antibiotic class to prevent guidelines or reverse resistance  Example forms available on Insufficient data to CDC website at: recommend routine use of /healthcare/improve- cycling for this purpose efforts/tools.html 13
  14. 14. 2. Supplemental Strategies Insufficient data to  Continuing broad therapy recommend routine use of contributes to selection of combination therapy to prevent resistance resistant pathogens Recommended Use  Recommended to use on  Empirical therapy for the basis of culture results critically ill patients with MDR pathogens  Decreases antimicrobial  Increase breadth of exposure coverage  Substantial cost savings  Increase likelihood of adequate initial therapy 14
  15. 15. 2. Supplemental Strategies Account for patient  Benefits characteristics, causative  Reduced length of hospital stay organism, infection site,  Decreased healthcare cost and pharmacokinetic and  Reduced incident of pharmacodynamic complications related to IV access characteristics of the drug  May be facilitated by the development of clinical Important component to criteria and guidelines antimicrobial stewardship allowing conversion 15
  16. 16. 3. Information Technology Options  Efficient targeting of  Computer Physician Order Entry (CPOE) antimicrobial interventions  Use of electronic medical records  Tracking of resistance patterns Incorporate data based computer-identified values  Microbiology C&S  Identification of Nosocomial  Hepatic and renal function Infections  Drug-drug interactions  Allergies  Cost  Identification of adverse drug events 16
  17. 17. 4. Microbiology Laboratory Critical role played in antimicrobial stewardship  Timely identification of pathogens  Performance of susceptibility testing  Assists infection control efforts in resistance surveillance Recommended Responsibilities  Routine Susceptibility testing  Resistance surveillance involvement • Local antibiograms updated at least annually  Partner with infection control to investigate local outbreaks of infection 17
  18. 18. 5. Monitoring of Process and Outcome Measurements • Did the intervention  Useful in determiningProcess result in the desired impact of theMeasures change in program on antimicrobial use? antimicrobial use and resistance patterns  Investment in data • Did the process systems to allow forOutcome implemented reduce evaluation as aMeasures or prevent unintended routine measure of consequences? quality improvement 18
  19. 19. 6. Comprehensive Multidisciplinary Antimicrobial Management Programs Antimicrobial stewardship requires a team approach that incorporates each element simultaneously Hospital administrative support is essential Consensus building between administration and providers should focus on patient safety and care rather than policing These programs consistently demonstrate decrease in antimicrobial use and hospital cost which pays for the program 19
  20. 20. The Stewardship Team  Infectious Diseases Physician  Clinical Pharmacist with ID Training  Clinical Microbiologist  Information System Specialist  Infection Control Professional  Hospital Epidemiologist 20
  21. 21. Recommended for Investigation Validation that Heterogeneous Long-term Impact ofAntimicrobial Cycling Antimicrobial Use Formulary Restriction Slows Resistance and Preauthorization Spread Evaluation of The Ability of Examination of Approaches that Antimicrobials to Strategy Efficacy inIncorporate Many of Cause “Collateral Subpopulations of the Most Effective Damage” or Hospitalized Patients Strategies Ecological Resistance Development andRole of Antimicrobial Determination of the Validation of Stewardship Relative Impact of Automated Combined with ASPs on Specific Surveillance Strategies Infection Control Resistant Bacteria for Nosocomial Practices Infections 21
  22. 22. Recommended for Investigation Decision Support Development and Cost- Strategies to StimulateSystems Incorporation effectiveness of more Research and Antimicrobial rapid and sensitive Development of NovelStewardship into CPOE diagnostic tests Antimicrobials Education and Training Influence of of Infectious Diseases Pharmaceutical Industry Fellows and Pharmacists and Representatives on in Antimicrobial Antimicrobial Prescribing Stewardship 22
  23. 23. Recent Recommendations SHEA, IDSA, PIDS April 20121. Antimicrobial stewardship programs should be required through regulatory mechanisms  Recommended that Centers for Medicare and Medicaid Services require participating healthcare institutions develop and implement ASPs  CMS should improve programs by requiring additional activities2. Antimicrobial stewardship should be monitored in ambulatory healthcare settings3. Education about antimicrobial resistance and antimicrobial stewardship must be accomplished 23
  24. 24. Recent Recommendations SHEA, IDSA, PIDS April 2012 4. Antimicrobial use data should be collected and readily available for both inpatient and outpatient settings 5. Research on antimicrobial stewardship is needed and should be funded by the appropriate federal agencies 24
  25. 25. Recent Recommendations SHEA, IDSA, PIDS April 2012Recommended Minimum Requirements for ASPs Multidisciplinary team  Additional interventions including to improve use of  A physician antimicrobials  A pharmacist  Processes to measure  A clinical microbiologist and monitoring  An infection antimicrobial use at the preventionist institutional level Limited formulary  Periodic distribution of a Institutional guidelines facility-specific for managing common antibiogram infection syndromes 25
  26. 26. Pharmacist Role in Antimicrobial Stewardship“Pharmacists have a responsibility to take prominent roles in antimicrobial stewardship programs and participate in the infection prevention and control programs of health systems” American Society of Health-System Pharmacists Position Statement, 2010 26
  27. 27. Responsibilities of Pharmacists Promoting Optimal Use of Antimicrobial Agents Reducing Transmission of Infections Educating Health Professionals, Patients, and the Public 27
  28. 28. Responsibility to Promote Optimal Use of Antimicrobials Encourage multidisciplinary  Work with laboratory collaboration personnel to ensure Work within the P&T appropriate susceptibility Committee, or equivalent tests are reported in a timely structure, to ensure the manner appropriate agents are  Work to compile and available distribute susceptibility reports at least annually Operate an ASP that utilizes patient outcomes to assess  Utilize information effectiveness of policies technology to enhance stewardship through Generate and analyze surveillance quantitative data on antimicrobial drug use to  Facilitate safe medication perform outcome analysis management practices 28
  29. 29. Responsibility to Reduce Transmission of Infections Participate in the infection  Encourage routine immunization prevention and control of staff and those who may committee impact the patient care environment Establish internal pharmacy  Promote adherence to standard policies, procedures and precautions by those who quality-control programs to impact the patient care prevent contamination of environment pharmacy products  Collaborate in the development Encourage use of single-dose of guidelines for risk assessment, packages rather than treatment, and monitoring of multiple-dose containers individuals in contact with a transmissible infectious disease Recommend proper labeling, dating, and storage of sterile  Strive for zero-tolerance of products and their containers health-care associated infections 29
  30. 30. Responsibility to Educate Others Provide educational forums  Participate in public health for healthcare professionals education and awareness on stewardship-related topics programs aimed and controlling spread of infectious disease  Antimicrobial use and resistance  Prudent use of antimicrobials  Decontaminating agents  Immunization access for children and adults  Aseptic technique and  Appropriate infection procedures prevention and control  Sterilization methods measures Educate and counsel patients  Provide exposure to regarding adherence to antimicrobial stewardship and prescribed directions, storage infection prevention and control and handling, proper disposal, practices through training for and other infection control pharmacists, students, residents and research fellows procedures 30
  31. 31. Review CaseJM is an active 15 year old girl who enjoys playingsoftball, swimming and running track. She was initiallypresented by her mother to the ER with a temperatureof 103 and complaining of fatigue x 1 week and pain inher hip.During the admission her WBC countswere normal and doctors stated therewere no signs of infection. She wassent home with a prescription foribuprofen and told to follow-up in 3days. 31
  32. 32. Review CaseWithin 2 days she was brought backed to the ER as her symptomsseemed to worsen. She was admitted and blood cultures returnedpositive for Staphylococcus Aureus. JM was diagnosed with sepsis thathad begun as an abscess growing in her hip. The infection was accompanied by many complications including a DVT leading to PE, and pneumonia requiring intubation. Eventually, JM developed infections caused by multiple MDR organisms including ESBL- producing E. coli, S. Maltophilia, and Enterobacter aerogenesThe only antibiotic available to treat her infections was colistin. 5months later, after a lung transplant, suffering a stroke, and losing 30lbs, JM was discharged home. Her entire stay totaled 6 million dollarsin healthcare costs 32
  33. 33. Questions to Consider What roles could antimicrobial stewardship have played in this case...  To prepare for such a situation prior to admission?  To preventing nosocomial infections during admission? What future changes could be made to the hospital’s policy? What role did or could have pharmacists played in this case?  Interventions  Patient, family, or provider education 33
  34. 34. True or False Questions1. Audits of restrictions and formularies are recommended by the IDSA as key antimicrobial stewardship activity2. Antimicrobial stewardship is True False the practice of using antimicrobials appropriately3. Antimicrobial stewardship does not need to be monitored in ambulatory healthcare settings 34
  35. 35. References ASHP Statement on the Pharmacist’s Role in Antimicrobial Stewardship and Infection Prevention and Control. Am J Health-Sys Pharm.2010;67:575-7. Dellit TH, Owens RC, McGowan JE, et al. Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America Guidelines for Developing and Institutional Program to Enhance Antimicrobial Stewardship. Clinical Infectious Diseases, 2007;44:159-177. Infectious Diseases Society of America. The 10x20 Initiative: pursuing a global commitment to develop 10 new antibacterial drugs by 2020. Clin Infect Dis 2010;50;1081-1083. Goff DA, Bauer KA, Mangino JE. “Antimicrobial Stewardship Management of Infections: Beyond the Cost of Antimicrobials”. Pharmacy Practice News. McMahon Publishing, August 2012. Society for Healthcare Epidemiology of America; Infectious Diseases Society of America; Pediatric Infectious Diseases Society. “Antimicrobial Stewardship Policy Statement”. Infection Control and Hospital Epidemiology, April 2012; 33(4):322-327. 35