Antibiotic stewardship programme hiht final 3nov2012

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  • Recommendation from the Infectious Disease Society of America (IDSA) Endorsed by the ASHP Board of Directors in March of 2006 Includes the IDSA Ranking System for Clinical Guidelines Official journal of the IDSA - Clinical Infectious Diseases Much recent support to institute management services in your institution Historically non-pharmacy friendly organization
  • Not another disease treatment where you must weigh your current patient’s treatment, with how that impacts future patients in your HC system Mortality affected when tx in inappropriate Resistance increases with broad spectrum agents needed, negative impact on outcomes
  • Clear association between resistance and increased morbidity/mortality and cost Inappropriate use is rampant—reason is that it is REALLY COMPLEX and DIFFICULT 10 × 20 initiative has been likened to John F. Kennedy’s dream of walking on the moon.
  • OK, we are back to our definition Remember infection control and its importance Mandatory infection control compliance plus antimicrobial management Appropriate antimicrobial selection, dosing, route, and duration Selection of antimicrobials that cause the least collateral damage (emergence of resistance, adverse drug events, and cost) MRSA ESBLs Clostridium difficille Stable derepression Metallo-beta-lactamases and other carbapenemases VRE
  • Do not include outpatient recommendations Financially self-supporting Improve patient care Should be evidence based
  • Do not include outpatient recommendations Financially self-supporting Improve patient care Should be evidence based
  • Do not include outpatient recommendations Financially self-supporting Improve patient care Should be evidence based
  • Do not include outpatient recommendations Financially self-supporting Improve patient care Should be evidence based
  • Do not include outpatient recommendations Financially self-supporting Improve patient care Should be evidence based
  • Infectious diseases specialists are one important resource for providing input, but many other professionals also contribute to optimal care for patients with infections. Like all patient safety endeavors, multidisciplinary collaboration is key! ESSENTIAL COLLABORATION Hospital administration Medical staff Infection Control Committee Pharmacy and Therapeutics Committee Approval of pathways Review of budgetary issues Approval of restriction policies and procedures Review of yearly antibiogram
  • Infectious diseases specialists are one important resource for providing input, but many other professionals also contribute to optimal care for patients with infections. Like all patient safety endeavors, multidisciplinary collaboration is key! ESSENTIAL COLLABORATION Hospital administration Medical staff Infection Control Committee Pharmacy and Therapeutics Committee Approval of pathways Review of budgetary issues Approval of restriction policies and procedures Review of yearly antibiogram
  • In some hospitals, the pharmacy will not dispense certain antimicrobial agents without the approval of a physician trained in ID. This practice reduces both the use and costs of these agents. In several studies, this practice and other methods used to restrict antimicrobial use have decreased the incidence of certain drug-resistant organisms in healthcare settings. IDSA’s Emerging Infections Network (EIN) surveyed its members to characterize antimicrobial restriction policies in their hospitals and the involvement of ID consultants in this process. 502 responded to the survey. Almost all respondents agreed that inappropriate use of antibiotics is the most important factor contributing to increased antibiotic resistance. Nearly all respondents agreed that ID consultants should be directly involved in the approval process of selected antimicrobials. However, there are many barriers to the involvement of ID consultants in this process. Primary among these barriers are Time and effort required to maintain an approval program Lack of compensation for such a role Fear of antagonizing colleagues from other specialties and consequent loss of income due to reduced consultations In the editorial comment on this paper, John E McGowan, Jr identifies several stakeholder groups that must be included in efforts to deal with resistance in the healthcare setting. These groups include: Prescribers Patients Healthcare administrators Institutional thought leaders Pharmacists, nurses, and laboratory personnel Antimicrobial use improvement and quality assurance groups Professional societies and the government
  • Illustrate antimicrobial eras during which new agents with new MOA came out Last breakthru drug of a new class (and not even a new MOA) in 1980s—carbapenem (imipenem) much more resistant to hydrolysis by PCNases/Cephalosporinases But, now this is changing IDSA/ICAAC posters for future agents: in phase III clinical trials = 0 Not much on the 10 year horizon Ceftibiprole=4 th gen ceph with MRSA coverage Dalpovancin=glycopeptide antibiotic 30 years with no new PA drugs 30 years with 1 new drug for other G- (tig) $1B investment, not much return, orgs pursuading congress to provide incentives to companies Drug on for short duration

Transcript

  • 1. Vikas KesarwaniVikas Kesarwani MD FICM FCCPMD FICM FCCP Asstt. Professor & In-charge,Asstt. Professor & In-charge, Department of Critical care medicineDepartment of Critical care medicine ANTIMICROBIAL STEWARDSHIP:ANTIMICROBIAL STEWARDSHIP: A CONCERN FOR ALL PRACTITIONERSA CONCERN FOR ALL PRACTITIONERS
  • 2. Guideline ResourcesGuideline Resources • IDSA and SHEAIDSA and SHEA – Guidelines for Developing an Institutional ProgramGuidelines for Developing an Institutional Program to Enhance Antimicrobial Stewardshipto Enhance Antimicrobial Stewardship • ASMASM – Antimicrobial Resistance Prevention Initiative—AnAntimicrobial Resistance Prevention Initiative—An UpdateUpdate IDSA: Infectious Disease Society of AmericaIDSA: Infectious Disease Society of America SHEA: Society of Heathcare Epidemiology of AmericaSHEA: Society of Heathcare Epidemiology of America ASM: American Society of MicrobiologyASM: American Society of Microbiology
  • 3. Appropriate initial antibioticAppropriate initial antibiotic (usually empirical)(usually empirical) whilewhile improvingimproving patientpatient outcomesoutcomes andand heathcareheathcare Appropriate initial antibioticAppropriate initial antibiotic (usually empirical)(usually empirical) whilewhile improvingimproving patientpatient outcomesoutcomes andand heathcareheathcare UnnecessaryUnnecessary AntibioticsAntibiotics (broad(broad spectrum) and increasedspectrum) and increased resistanceresistance andand costcost UnnecessaryUnnecessary AntibioticsAntibiotics (broad(broad spectrum) and increasedspectrum) and increased resistanceresistance andand costcost Antimicrobial Therapy :Antimicrobial Therapy : Anti-Anti- MicrobialMicrobial StewardshipStewardship A Balancing ActA Balancing Act
  • 4. Why Stewardship is Needed – Up toUp to 50% antimicrobial50% antimicrobial prescribingprescribing inappropriateinappropriate** – Causal relationshipCausal relationship betweenbetween antimicrobial useantimicrobial use andand emergence ofemergence of resistanceresistance – IDSA’s:IDSA’s: Bad Bugs, No Drugs task forceBad Bugs, No Drugs task force to call forto call for a global commitment from stakeholders to supporta global commitment from stakeholders to support thethe development of 10 new drugs indevelopment of 10 new drugs in novelnovel classesclasses by the year 2020by the year 2020:: 10 × 20 initiative10 × 20 initiative *Dellit TH et al. IDSA and SHEA guidelines. Clin inf dis 2007;44(2):159-177. IDSA: Infectious Diseases Society of America
  • 5. Those of us not developing new drugsThose of us not developing new drugs have another job:have another job: Conserve the antibiotics byConserve the antibiotics by Antibiotic stewardshipAntibiotic stewardship
  • 6. What is Antimicrobial Stewardship?What is Antimicrobial Stewardship? • ““The optimalThe optimal selectionselection,, dosagedosage, and, and durationduration ofof antimicrobial treatmentantimicrobial treatment thatthat results in theresults in the best clinical outcome”best clinical outcome” oror ““TreatmentTreatment andand prevention of infectionprevention of infection,, withwith minimal toxicityminimal toxicity to the patient andto the patient and minimal impactminimal impact on subsequenton subsequent resistanceresistance.”.” Dellit TH, et al. CID 2007;44:159-77,Dellit TH, et al. CID 2007;44:159-77, Hand K, et al. Hospital Pharmacist 2004;11:459-64Hand K, et al. Hospital Pharmacist 2004;11:459-64 Paskovaty A, et al IJAA 2005;25:1-10Paskovaty A, et al IJAA 2005;25:1-10
  • 7. 3 Goals of Antimicrobial Stewardship3 Goals of Antimicrobial Stewardship • 11stst Goal:Goal: each patient receive the mosteach patient receive the most appropriateappropriate antimicrobialantimicrobial • 2nd Goal:2nd Goal: preventprevent antimicrobialantimicrobial overuse, misuse, and abuse.overuse, misuse, and abuse. • 3rd Goal :3rd Goal : minimizeminimize the development ofthe development of resistance.resistance. • Secondary goalSecondary goal ReduceReduce healthcarehealthcare costscosts without adversely impactingwithout adversely impacting quality of carequality of care
  • 8. Goals of Antimicrobial StewardshipGoals of Antimicrobial Stewardship 11stst Goal:Goal: each patient receive the mosteach patient receive the most appropriate antimicrobialappropriate antimicrobial ““4 D’s4 D’s of optimal antimicrobial therapy”:of optimal antimicrobial therapy”: -- RightRight DrugDrug,, --RightRight DoseDose,, -- De-escalationDe-escalation to pathogen-directed therapy,to pathogen-directed therapy, -- RightRight DurationDuration of therapy.of therapy.
  • 9. Goals of Antimicrobial StewardshipGoals of Antimicrobial Stewardship • 22ndnd Goal: prevent antimicrobialGoal: prevent antimicrobial overuse, misuse, and abuse.overuse, misuse, and abuse. Overuse:Overuse: Antibiotics toAntibiotics to patients withpatients with viral infectionsviral infections,, noninfectious processes (noninfectious processes (pancreatitispancreatitis), infections), infections that do not require antibiotics (that do not require antibiotics (small skin abscessessmall skin abscesses that willthat will resolve with I & Dresolve with I & D), and), and bacterial colonizationbacterial colonization (positive urine culture result in(positive urine culture result in catheterized patient.).catheterized patient.).
  • 10. Goals of Antimicrobial StewardshipGoals of Antimicrobial Stewardship • 22ndnd Goal: prevent antimicrobialGoal: prevent antimicrobial overuse, misuse, and abuse.overuse, misuse, and abuse. • Misuse:Misuse: use ofuse of broad-spectrum antibioticsbroad-spectrum antibiotics that coverthat cover MDR organisms in a patient withMDR organisms in a patient with community acquiredcommunity acquired infectioninfection or theor the failure to adjust antibiotics accordingfailure to adjust antibiotics according to culture.to culture. • Abuse:Abuse: use of oneuse of one particular antibiotic preferentiallyparticular antibiotic preferentially over othersover others as a result ofas a result of aggressive detailing byaggressive detailing by pharmaceutical representativepharmaceutical representative or worse becauseor worse because ofof financial interest.financial interest.
  • 11. Goals of Antimicrobial StewardshipGoals of Antimicrobial Stewardship • 33rdrd Goal :Goal : minimizeminimize the development ofthe development of resistance.resistance. Antimicrobial resistance is associated withAntimicrobial resistance is associated with increased morbidity and mortalityincreased morbidity and mortality
  • 12. Building the Stewardship teamBuilding the Stewardship team Infectious DiseasesInfectious Diseases SpecialistsSpecialists AntimicrobialAntimicrobial ControlControl Infection ControlInfection ControlAdministrationAdministration ClinicalClinical PharmacistsPharmacists ID trainedID trained NursingNursing Surgical InfectionSurgical Infection Experts/SurgeonsExperts/Surgeons OT PersonnelOT Personnel MicrobiologistMicrobiologist IntensivistIntensivist
  • 13. The stewardship team does notThe stewardship team does not have to fit a particular mold.have to fit a particular mold.
  • 14. Building the Stewardship teamBuilding the Stewardship team Hospitalist interested inHospitalist interested in infectious diseaseinfectious disease AntimicrobialAntimicrobial ControlControl Infection ControlInfection ControlAdministrationAdministration NursingNursing Surgical InfectionSurgical Infection Experts/SurgeonsExperts/Surgeons OT PersonnelOT Personnel MicrobiologistMicrobiologist IntensivistIntensivist InfectionInfection preventionistpreventionist
  • 15. Antimicrobial StewardshipAntimicrobial Stewardship Core StrategiesCore Strategies
  • 16. IDSA Grading System for RankingIDSA Grading System for Ranking Recommendations in Clinical GuidelinesRecommendations in Clinical Guidelines Kish MA et al. CID 2001; 32: 851 - 4Kish MA et al. CID 2001; 32: 851 - 4 Category, GradeCategory, Grade DefinitionDefinition Strength ofStrength of recommendationrecommendation AA Good evidence to supportGood evidence to support BB Moderate evidence to supportModerate evidence to support CC Poor evidence to supportPoor evidence to support Quality of evidenceQuality of evidence II ≥≥ 1 randomized, controlled trials1 randomized, controlled trials IIII ≥≥ 1 clinical trial unrandomized, cohort1 clinical trial unrandomized, cohort or case-controlled studies, dramaticor case-controlled studies, dramatic results from uncontolled experimentsresults from uncontolled experiments IIIIII Opinion of experts, clinical experience,Opinion of experts, clinical experience, descriptive studiesdescriptive studies
  • 17. Antimicrobial Stewardship Core StrategiesAntimicrobial Stewardship Core Strategies • Front endFront end (pre-prescription approach):(pre-prescription approach): Formulary restrictionFormulary restriction andand preauthorizationpreauthorization (expert approval) leading to reductions in(expert approval) leading to reductions in antimicrobial use and cost .antimicrobial use and cost . (A II)(A II) • Back endBack end (Post prescription approach):(Post prescription approach): Interventions after antimicrobials have beenInterventions after antimicrobials have been prescribedprescribed. (A II). (A II) • Prospective audit with intervention and feedbackProspective audit with intervention and feedback ofof antimicrobial use and resistance patternsantimicrobial use and resistance patterns to reduceto reduce inappropriate antimicrobial useinappropriate antimicrobial use (A I)(A I) Dellit TH, et al. CID 2007;44:159-77Dellit TH, et al. CID 2007;44:159-77 Hand K, et al Hospital Pharmacist 2004;11:459-64Hand K, et al Hospital Pharmacist 2004;11:459-64 Paskovaty A, et al IJAA 2005;25:1-10Paskovaty A, et al IJAA 2005;25:1-10
  • 18. Core strategy “The Front End”Core strategy “The Front End” • Restrictive prescriptive authorityRestrictive prescriptive authority:: - Certain- Certain antimicrobialsantimicrobials requirerequire prior authorizationprior authorization for use by all except a select group of clinicians.for use by all except a select group of clinicians. - Approved- Approved for a specificfor a specific durationduration, thereby, thereby prompting reviewprompting review after cultureafter culture data obtained.data obtained. -- TargetTarget aa specific diseasespecific disease or indication withor indication with specific antimicrobialsspecific antimicrobials associated withassociated with highhigh ratesrates ofof resistance and costresistance and cost.. Advantage:Advantage: --PreventsPrevents overuse, misuseoveruse, misuse andand abuseabuse.. - Significant- Significant reduction in cost.reduction in cost.
  • 19. Core Strategy “The Back end”Core Strategy “The Back end” • Post prescription restriction: Uses prospective review andPost prescription restriction: Uses prospective review and feedback.feedback. • Specific AntimicrobialsSpecific Antimicrobials areare reviewed at specified intervalsreviewed at specified intervals after initiation. Adviced toafter initiation. Adviced to continue, adjust, change, orcontinue, adjust, change, or discontinuediscontinue the therapythe therapy based on microbiology resultsbased on microbiology results andand clinical featuresclinical features of the case.of the case. AdvantageAdvantage Focus is onFocus is on De-escalation.De-escalation. -- changing achanging a broad-spectrumbroad-spectrum antibiotic toantibiotic to narrow spectrumnarrow spectrum - changing from- changing from combinationcombination therapy totherapy to monotherapymonotherapy, or, or -- stopping antibioticstopping antibiotic therapy altogether as it becomes moretherapy altogether as it becomes more apparent that these drugs areapparent that these drugs are not needednot needed..
  • 20. Supplemental AntimicrobialSupplemental Antimicrobial Stewardship Strategies/TechniquesStewardship Strategies/Techniques – Education: clinical guidelines, infectionEducation: clinical guidelines, infection control.control. – Antimicrobial order formsAntimicrobial order forms – IV-PO switchIV-PO switch – Dose optimization via PK-PDDose optimization via PK-PD – Antimicrobial cyclingAntimicrobial cycling
  • 21. Educational StrategiesEducational Strategies • Educational programs, active interventionEducational programs, active intervention (A-III, B-II)(A-III, B-II) Guideline & algorithm dissemination.Guideline & algorithm dissemination. • Guidelines and clinical pathways –Guidelines and clinical pathways – seek multi-seek multi- disciplinary involvement and approvaldisciplinary involvement and approval (A-I)(A-I) – Incorporate local antimicrobial resistanceIncorporate local antimicrobial resistance patternspatterns (A-I)(A-I) – ProvideProvide education and feedbackeducation and feedback to practitionersto practitioners (A-III)(A-III) idea ?idea ? Microbiology Newsletter.Microbiology Newsletter. Questions of theQuestions of the week/monthweek/month
  • 22. Antimicrobial order forms (B-II)Antimicrobial order forms (B-II) Shown to be effective component of the programShown to be effective component of the program and canand can facilitate planningfacilitate planning intointo practice.practice. HelpsHelps auditaudit andand feedback.feedback. – ensuresensures guideline-basedguideline-based appropriateappropriate empiricempiric antibioticantibiotic ordering.ordering. – Day 3 reviewDay 3 review bundlebundle based on investigations andbased on investigations and clinical profile.clinical profile. – Streamlining orStreamlining or de-escalationde-escalation therapytherapy (A-II)(A-II) Antimicrobial order formsAntimicrobial order forms
  • 23. Day 3 Antibiotic Review BundleDay 3 Antibiotic Review Bundle Pulcini et al, JAC, 2008Pulcini et al, JAC, 2008
  • 24. Parenteral to Enteral conversionParenteral to Enteral conversion (A-I)(A-I) – As soon as the patient’s condition allowsAs soon as the patient’s condition allows • Reduces length of stayReduces length of stay && healthcare costshealthcare costs I.V. to oral switch overI.V. to oral switch over Dose optimization via PK-PDDose optimization via PK-PD Dose optimizationDose optimization (A-II)(A-II) Based onBased on Organ dysfunctionOrgan dysfunction.. Patient characteristicsPatient characteristics (wt, age, sex,(wt, age, sex, ethnicity),ethnicity), CausativeCausative organismorganism ((virulencevirulence),), SiteSite of infection (drug delivery to that site)of infection (drug delivery to that site)
  • 25. – Hypothesis:Hypothesis: byby removing specific classesremoving specific classes ofof antimicrobialsantimicrobials on a regular basison a regular basis, the, the development of resistance can be avoided.development of resistance can be avoided. Antimicrobial cycling – isAntimicrobial cycling – is not recommendednot recommended because ofbecause of insufficient datainsufficient data (no ranking)(no ranking) Antimicrobial cyclingAntimicrobial cycling ………………………………….
  • 26. Barriers to Implementing AntibioticBarriers to Implementing Antibiotic stewardship programmestewardship programme
  • 27. The Vicious Spiral: The Prescriber’s dilemma --Must get right at allMust get right at all cost.cost. -Blanket cover is less-Blanket cover is less stressful.stressful. -Lack of faith in tests-Lack of faith in tests -Defensive medicine-Defensive medicine ↑↑ use of newuse of new drugsdrugs ↑↑ Use of broadUse of broad spectrum drugsspectrum drugs ↑↑ C.difficleC.difficle ↑↑ costcost ↑ResistanceResistance
  • 28. Barriers to Implementing AntibioticBarriers to Implementing Antibiotic stewardship programmestewardship programme Lack of understanding of problem…Who cares..Lack of understanding of problem…Who cares.. – Staff may not want to assume “added”Staff may not want to assume “added” responsibility.responsibility. (No compensation)(No compensation).. – The paradoxThe paradox:: higherhigher thethe antibiotic demandantibiotic demand moremore earning,earning, happierhappier thethe beneficiariesbeneficiaries.. – ““ManyMany clinicians might feel offendedclinicians might feel offended to their rightto their right to prescribe antibiotics freely (unrestricted)”to prescribe antibiotics freely (unrestricted)” -Sunenshine RH, et al.-Sunenshine RH, et al. Clin Infect DisClin Infect Dis 2004;38:934-38.2004;38:934-38. -Arvind Kejriwal-Arvind Kejriwal IACIAC
  • 29. We can still do much without problem. Every ounce of stewardship countsEvery ounce of stewardship counts – start small,– start small, think bigthink big!!
  • 30. We can still do a lot…..We can still do a lot….. • Form anForm an Antibiotic stewardship teamAntibiotic stewardship team withwith Hospitalists interested in infectiousHospitalists interested in infectious diseasedisease.. • Educate:Educate: clinical guidelines, algorithms,clinical guidelines, algorithms, infection control techniques.infection control techniques. • Day 3 Antibiotic Review form.Day 3 Antibiotic Review form.
  • 31. Day 3 Antibiotic Review form Pulcini et al, JAC, 2008 -IV-PO switch.IV-PO switch. -De-escalation.De-escalation. -Audit and feedback.Audit and feedback.
  • 32. We can still do a lot…..We can still do a lot….. • Form anForm an Antibiotic stewardship teamAntibiotic stewardship team withwith Hospitalists interested in infectious diseaseHospitalists interested in infectious disease.. • Educate:Educate: clinical guidelines, algorithms, infectionclinical guidelines, algorithms, infection control techniques.control techniques. • Day 3 Antibiotic Review form.Day 3 Antibiotic Review form. -- IV-PO switch.IV-PO switch. - De-escalation.- De-escalation. - Audit and feedback.- Audit and feedback. • PosterPoster ofof empiric treatment guidelineempiric treatment guideline.. • Microbiology newsletterMicrobiology newsletter with microbial resistancewith microbial resistance review and feedback.review and feedback. ………………………….
  • 33. A Disturbing Trend 1930 1940 1950 1960 1970 1980 1990 2000 2010 Sulfa, BL, AG, Chloramphenicol TCN, MAC, Vanc, RIF, FQ, TMP No new classes. Modification of existing agents. LZD, DAP, TIG CBP; DAL; New Entities Limited PCN-resistant S. aureus MRSA VRE VISA in 7 states VRSA LZD-R S. aureus MDR Pseudomonas and Acinetobacter, metallo-beta-lactamases, carbapenemases Half of US and Japanese companies END drug discovery
  • 34. Computer Surveillance • Sentri7 • SafetySurveillor-Pharmacy • TheraDoc • CPOE • Benchmarking • Antimicrobial use