Antimicrobial Use BundleAntimicrobial Use Bundle
An idea whose time has come ?An idea whose time has come ?
Dr. Ashok Ratt...
Antimicrobial Prescribing Facts
• ~ 1/3 of all hospitalised inpatients at any given time receive
antibiotics
• ~ up to 1/3...
100
80
60
40
20
0
19801975 1985 1990 1995 2000
1997
VISAVISA
VREVRE
PRSPPRSP
MRSAMRSA
MRSEMRSE
Percentage
of
Pathogens
Res...
South Atlantic OceanSouth Pacific Ocean
North Pacific Ocean
North Atlantic Ocean
Indian Ocean
Arctic Ocean Arctic OceanArc...
Geographical Distribution of
KPC-Producers
Frequent Occurrence
Sporadic Isolate (s)
NDM 1
Consequences of antibiotic use
•Clinical cure
•Inhibition of non pathogenic bacteria
•Selection of resistant mutants
•Toxi...
Antimicrobial Stewardship
Prudent use of antibiotics +
Infection control
Clinical cureClinical cure
•Inhibition of non pat...
Antibiotic Stewardship
• Effective antimicrobial stewardship
– Audit & feedback
– Guidelines & algorithms
– Antibiotic ord...
Antibiotic Stewardship
• Comprehensive Infection control
– Managing data and information
– Policies & procedures
– Regulat...
Antibiotic Guidelines
Linear Causation Process
Single intervention is effective
e.g. vaccination
Non linear web of causation
Multiple intervention required
Four processes working at 88% can summate to as little as
50% likelihood that each patient will experience
100% correct pr...
What Is a Bundle?
• A grouping of best practices that individually
improve care, but when applied together result in
subst...
What is a bundle ?
• Structured way of improving process of care
& patient outcomes
• Small, straight forward set of pract...
• The premise of a bundle:
– Reduce variation in practice
– Build a collaborative environment
– Bring about change
– Promo...
Antimicrobial Use Bundle
Initiation bundle:
1. 1. Clinical rationale for antibiotic initiation documented
2. 2. Appropriat...
Antimicrobial Use Bundle
Day 3 bundle:
1. 1. Was an antibiotic plan documented
1. (name, dose, route, frequency & planned ...
Antimicrobial Use Bundle
For Surgical Prophylaxis:
1. 1. Agent selected matches local guidelines for
that operation and fo...
Fortis HospitalFortis Hospital
Antimicrobial Use Bundle Data Collection Form (Summary)Antimicrobial Use Bundle Data Collec...
Fortis HospitalFortis Hospital
Antimicrobial Use Bundle Data Collection Form: InitiationAntimicrobial Use Bundle Data Coll...
Fortis HospitalFortis Hospital
Antimicrobial Use PlanAntimicrobial Use Plan
Fortis HospitalFortis Hospital
Antimicrobial Use Bundle Data Collection Form: Day 3Antimicrobial Use Bundle Data Collectio...
Fortis HospitalFortis Hospital
Antimicrobial Use Bundle Data Collection Form (Prophylaxis)Antimicrobial Use Bundle Data Co...
Implementation of a care bundle for
antimicrobial stewardship
Toth NR et al. Am J Health Syst Pharm 2010; 67: 746 - 749
• ...
Implementation of a care bundle for
antimicrobial stewardship
Toth NR et al. Am J Health Syst Pharm 2010; 67: 746 - 749
• ...
Impact of standardised review of intravenous antibiotic therapy
72 hours after prescription in two internal medicine wards...
Impact of standardised review of intravenous antibiotic therapy
72 hours after prescription in two internal medicine wards...
Impact of standardised review of intravenous antibiotic therapy
72 hours after prescription in two internal medicine wards...
Other indicators forOther indicators for
Antimicrobial StewardshipAntimicrobial Stewardship
• Antimicrobial costsAntimicro...
Attributable costs of HAI
Stone et al AJIC 2005; 33(9): 501-509
Infection Mean Cost
($ US)
SD Minimum Maximum
Surgical Sit...
Socio-economic burden of hospital-
acquired infections (HAIs)
Incidence Duration of
Stay
Overall costs Specific costs %
7....
“Whether ‘tis nobler in the mind to suffer
the slings and arrows
of outrageous… [prescribing]..
or take to arms against a ...
Antimicrobial bundle
Antimicrobial bundle
Antimicrobial bundle
Antimicrobial bundle
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Antimicrobial bundle

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Antimicrobial care bundle helps to convert antibiotic policies into action at the bedside

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  • Mixed; 29 reported Yes, they conducted some surveillance activity for MRSA; 23 had MRSA reportable in some form and all or selected area.
  • From Tom Rainey’s presentation….need MMWR citation
  • Antimicrobial bundle

    1. 1. Antimicrobial Use BundleAntimicrobial Use Bundle An idea whose time has come ?An idea whose time has come ? Dr. Ashok Rattan, Chief Executive, Fortis Clinical research Ltd., Adviser, Religare SRL Diagnostics labs in Fortis / Escorts Hospitals, Delhi & NCR
    2. 2. Antimicrobial Prescribing Facts • ~ 1/3 of all hospitalised inpatients at any given time receive antibiotics • ~ up to 1/3 to ½ are inappropriate • ~ up to 30% of all surgical prophylaxis in inappropriate • Antimicrobials account for upwards of 30% of hospital pharmacy budgets. Stewardship programmes can save up to 10% of pharmacy budgets. • Inappropriate and excessive use leads to resistance, C.difficle & other ecological consequences, increased morbidity, mortality, increased cost, increased litigation and reduce quality of life
    3. 3. 100 80 60 40 20 0 19801975 1985 1990 1995 2000 1997 VISAVISA VREVRE PRSPPRSP MRSAMRSA MRSEMRSE Percentage of Pathogens Resistant to Antibiotics Increasing Incidence of Resistance in the US MRSE, MRSA, VRE, PRSP, GISA 1980-2006 VRSAVRSA 2006
    4. 4. South Atlantic OceanSouth Pacific Ocean North Pacific Ocean North Atlantic Ocean Indian Ocean Arctic Ocean Arctic OceanArctic Ocean North Pacific Ocean United States of America U.S.A. Canada Mexico Brazil U.S.A. French Polynesia(Fr.) Argentina Uruguay Paraguay Chile Bolivia Peru Ecuador Colombia Venezuela Greenland (Den.) Iceland Madagascar South AfricaLesotho Swaziland Mozambique Tanzania Botswana Namibia Zimbabwe Angola Zaire Zambia Malawi Burundi KenyaRwanda Uganda Congo Gabon Somalia Ethiopia Sudan EgyptLibya Chad Niger Algeria MaliMauritania Morocco Finland Norway Sweden Turkey Yemen Oman Saudi Arabia Iran China Mongolia Russia India Indonesia Malaysia Australia Japan Antarctica Kazakhstan Hawaiian Islands 120° 60° 0° 60° 120° 180° 60° 30° 0° 30° 60° 180°150°120°90°30°0°30°60°90°120°150° 60° 30° 0° 30° 60° 60° USA 34% Latin America 45% Europe 9-54% Russia 40-90% China 34-38% Taiwan Philipines Singapore > 20% Africa > 20% ESBL is world wide in distribution Multiple sources & references India 30-80%
    5. 5. Geographical Distribution of KPC-Producers Frequent Occurrence Sporadic Isolate (s)
    6. 6. NDM 1
    7. 7. Consequences of antibiotic use •Clinical cure •Inhibition of non pathogenic bacteria •Selection of resistant mutants •Toxicity / side effects
    8. 8. Antimicrobial Stewardship Prudent use of antibiotics + Infection control Clinical cureClinical cure •Inhibition of non pathogenic bacteria •Selection of resistant mutants •Toxicity / side effects
    9. 9. Antibiotic Stewardship • Effective antimicrobial stewardship – Audit & feedback – Guidelines & algorithms – Antibiotic order form – Combination – De escalation – Dose optimization – Parentral  oral – Cycling
    10. 10. Antibiotic Stewardship • Comprehensive Infection control – Managing data and information – Policies & procedures – Regulatory requirements – Employee health – Prevent transmission, investigate outbreaks – Education & training – Mobilize resources: human & financial
    11. 11. Antibiotic Guidelines
    12. 12. Linear Causation Process Single intervention is effective e.g. vaccination
    13. 13. Non linear web of causation Multiple intervention required
    14. 14. Four processes working at 88% can summate to as little as 50% likelihood that each patient will experience 100% correct process
    15. 15. What Is a Bundle? • A grouping of best practices that individually improve care, but when applied together result in substantially greater improvement. • Science behind the bundle elements is well established – the standard of care. • Bundle element compliance can be measured as “ yes/no.” • “All or none” approach.
    16. 16. What is a bundle ? • Structured way of improving process of care & patient outcomes • Small, straight forward set of practices (3 to 5) which when performed collectively, reliably & continuously have been proven to improve patient outcomes • Data from these frequent measures is fed back to those involved in the procedures • Reduction in negative actions
    17. 17. • The premise of a bundle: – Reduce variation in practice – Build a collaborative environment – Bring about change – Promote problem solving ability of the staff
    18. 18. Antimicrobial Use Bundle Initiation bundle: 1. 1. Clinical rationale for antibiotic initiation documented 2. 2. Appropriate samples for smear & culture collected & submitted to the laboratory 3. 3. Antibiotic selected according to local policy & risk group 4. 4. Antibiotic ordered as per plan 1. (name, dose, route, frequency & tentative duration) 5. 5. Removal of foreign body or ID, as appropriate, considered
    19. 19. Antimicrobial Use Bundle Day 3 bundle: 1. 1. Was an antibiotic plan documented 1. (name, dose, route, frequency & planned duration ?) 2. 2. Review of diagnosis after lab reports ? 3. 3. If positive microbiology results, was there any adaptation : streamlining or discontinuation 4. 4. Was IV -> oral switch considered & implemented 5. 5. Were all four above mentioned steps followed ?
    20. 20. Antimicrobial Use Bundle For Surgical Prophylaxis: 1. 1. Agent selected matches local guidelines for that operation and for that patient 2. 2. Timing of first dose in 30 min to 1 hour before incision 3. 3. Antibiotic stopped by 24 hours after the pre operative dose
    21. 21. Fortis HospitalFortis Hospital Antimicrobial Use Bundle Data Collection Form (Summary)Antimicrobial Use Bundle Data Collection Form (Summary)
    22. 22. Fortis HospitalFortis Hospital Antimicrobial Use Bundle Data Collection Form: InitiationAntimicrobial Use Bundle Data Collection Form: Initiation
    23. 23. Fortis HospitalFortis Hospital Antimicrobial Use PlanAntimicrobial Use Plan
    24. 24. Fortis HospitalFortis Hospital Antimicrobial Use Bundle Data Collection Form: Day 3Antimicrobial Use Bundle Data Collection Form: Day 3
    25. 25. Fortis HospitalFortis Hospital Antimicrobial Use Bundle Data Collection Form (Prophylaxis)Antimicrobial Use Bundle Data Collection Form (Prophylaxis)
    26. 26. Implementation of a care bundle for antimicrobial stewardship Toth NR et al. Am J Health Syst Pharm 2010; 67: 746 - 749 • 903 bed tertiary care hospital in Michigen • Decided to: – Employ a trained pharmacist to perform antibiotic audit – Daily monitoring of culture & susceptibility results – Suggest changes to empirical & definitive antimicrobial – Provide educational in service program focused on hospitals own antibiogram • Study: – Retrospective control: Sept – Nov 2007 – Bundle intervention : Feb – Apr 2008 • Inclusion: – Pts receiving antibiotics admitted into Medical & Surgical wards, 85 antibiotic orders to detect a 20% difference in compliance with beta 0.2 and alpha of 0.05
    27. 27. Implementation of a care bundle for antimicrobial stewardship Toth NR et al. Am J Health Syst Pharm 2010; 67: 746 - 749 • Compliance with Quality Indicators of Antibiotic Use Indicator Control Intervention p . 1. Document indication 76 80 0.12 2. Appropriate cultures 70 76 0.09 3. Appropriate empirical 55 65 0.06 4. Appropriate deescalation 41/57 52/58 0.01 5. All indicators concurrently 13 43 <0.001
    28. 28. Impact of standardised review of intravenous antibiotic therapy 72 hours after prescription in two internal medicine wards. Manuel O, Burnand B, Bady P, Kammerlander R, Vansantvoet M., Francioli P, Zanetti G: Journal of Hospital Infection 2010: 74; 326- 331 • Intervention : 196 patients 204 courses • Control : 226 208 • Modification proposed: 93 (46%) of 204 courses – IV -> Oral switch : 48 (23%) – Discontinuation : 16 (8) – Change antibiotic : 32 (16) – Dose modification : 4 (2) • Compliance with suggestion: 70 / 93 (75%) • Mean duration : 3.9 + 5.2 days 5 + 6 days • Consumption : • Cost : • Mortality : 11.4 (%) 17.4 • Length of stay : 19 + 25 17 + 22
    29. 29. Impact of standardised review of intravenous antibiotic therapy 72 hours after prescription in two internal medicine wards. Manuel O, Burnand B, Bady P, Kammerlander R, Vansantvoet M., Francioli P, Zanetti G: Journal of Hospital Infection 2010: 74; 326- 331
    30. 30. Impact of standardised review of intravenous antibiotic therapy 72 hours after prescription in two internal medicine wards. Manuel O, Burnand B, Bady P, Kammerlander R, Vansantvoet M., Francioli P, Zanetti G: Journal of Hospital Infection 2010: 74; 326- 331
    31. 31. Other indicators forOther indicators for Antimicrobial StewardshipAntimicrobial Stewardship • Antimicrobial costsAntimicrobial costs • Resistant trendsResistant trends • Days on therapyDays on therapy • Defined daily DoseDefined daily Dose
    32. 32. Attributable costs of HAI Stone et al AJIC 2005; 33(9): 501-509 Infection Mean Cost ($ US) SD Minimum Maximum Surgical Site Infection 25546 39875 1783 134602 BI 36441 37078 1822 107156 VAP 9969 2920 7904 12034 UTI 1006 503 650 1361
    33. 33. Socio-economic burden of hospital- acquired infections (HAIs) Incidence Duration of Stay Overall costs Specific costs % 7.8% 11 days GBP 2915 Hospital overheads / capital charges / management 33 Acquired one or more HAIs whilst in hospital 2.5 times more than uninfected 2.8 times longer than uninfected Nursing care Operations/ Consumables Paramedics/ nurses Antimicrobials Others 42 7 6 4 2
    34. 34. “Whether ‘tis nobler in the mind to suffer the slings and arrows of outrageous… [prescribing].. or take to arms against a sea of.. [resistance and diarrhoea].. and by opposing [irrational antibiotics prescribing] help end it..” With apologies to William Shakespeare
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