Recommended
More Related Content
What's hot
What's hot (20)
Similar to Antibiotic Stewardship ppt.pptx
Similar to Antibiotic Stewardship ppt.pptx (20)
More from Afkar432
More from Afkar432 (13)
Recently uploaded
Recently uploaded (20)
Antibiotic Stewardship ppt.pptx
- 1. Antibiotic Stewardship Presenter Dr. Nizar Muhammad (PharmD, MS (Pharm)) Pharmacist (Health Department) Saidu Group of Teaching Hospitals Swat
- 2. Objectives • Objectives: • To understand the purpose of implementing an antimicrobial stewardship program (ASP) • To recall the core elements of hospital and outpatient antibiotic stewardship programs as defined by the CDC • To recognize key interventions that an antimicrobial stewardship program can implement in both the hospital and community settings 1
- 4. What is Antimicrobial Resistance? • The ability of a microorganism to stop an antimicrobial from working against it. • Standard treatments become ineffective, infections persist and may spread to others. • New resistance mechanisms are emerging and spreading globally. • Resistance increases the cost of health care with lengthier stays in hospitals and more intensive care required. 3 who.int/antimicrobial-resistance
- 6. Spreading Antimicrobial Resistance 5 Antibiotic Resistance Threats in the United States. CDC. 2013.
- 7. Antimicrobial Development 6 Trends In Microbiology. 2014;22(4):165-167.
- 8. PART 2: A Piece of the puzzle 7
- 9. Fighting Back! • The CDC has recommended four necessary actions to prevent antimicrobial resistance • Prevent infections, prevent the spread of resistance • Tracking • Developing new drugs and diagnostic tests • IMPROVING ANTIBIOTIC PRESCRIBING / STEWARDSHIP 8 Antibiotic Resistance Threats in the United States. CDC. 2013.
- 10. What is Antimicrobial Stewardship? • The commitment to always use antibiotics appropriately and safely— only when they are needed to treat disease, and to choose the right antibiotics and to administer them in the right way in every case—is known as antibiotic stewardship. • Objectives: • Maximum antimicrobial benefit • Avoid harm from adverse reactions and drug allergies • Improve patient outcomes • Decrease antimicrobial resistance • Decrease healthcare costs 9 Antibiotic Resistance Threats in the United States. CDC. 2013.
- 11. 10 CDC. Core Elements of Hospital Antibiotic Stewardship Programs. 2014.
- 12. Leadership Commitment • Formal statements that the facility supports efforts to improve and monitor antibiotic use • Including stewardship-related duties in job descriptions and annual performance reviews • Ensuring staff from relevant departments are given sufficient time to contribute to stewardship activities • Supporting training and education • Ensuring participation from the many groups that can support stewardship activities 11 CDC. Core Elements of Hospital Antibiotic Stewardship Programs. 2014.
- 13. Accountability and Drug Expertise • Stewardship program leader: • Identify a single leader who will be responsible for program outcomes • Physicians have been highly effective in this role • Pharmacy leader: • Identify a single pharmacy leader who will co-lead the program • Key support: • The work of stewardship program leaders is greatly enhanced by the support of other key groups in hospitals where they are available • Clinicians and department heads, infection preventionists, hospital epidemiologists, quality improvement staff, laboratory staff, information technology staff, nursing 12 CDC. Core Elements of Hospital Antibiotic Stewardship Programs. 2014.
- 14. Action • Implement policies that support optimal antibiotic use • Document dose, duration, and indication • Develop and implement facility-specific treatment recommendations • Utilize specific interventions, divided into three categories: • Broad • Pharmacy driven • Infection and syndrome specific • Avoid implementing too many policies and interventions simultaneously • Prioritize based on the needs of the hospital as defined by measures of overall use and other tracking and reporting metrics 13 CDC. Core Elements of Hospital Antibiotic Stewardship Programs. 2014.
- 15. Interventions: Broad • Antibiotic “time-outs” • Prompts a reassessment of the continuing need and choice of antibiotics • Review after 48 hours • Prior authorization • Restrict the use of certain antibiotics • Based on the spectrum of activity, cost, or associated toxicities • Ensure that timely expert review is conceivable to avoid delay in therapy • Prospective audit and feedback • External reviews of antibiotic therapy by an expert in antibiotic use • Major function of the ASP pharmacist 14 CDC. Core Elements of Hospital Antibiotic Stewardship Programs. 2014.
- 16. Interventions: Pharmacy Driven • Automatic changes from intravenous to oral antimicrobial therapy • Dose adjustments • Dose optimization • Automatic alerts in situations where therapy might be unnecessarily duplicative • Time-sensitive automatic stop orders • Detection and prevention of antimicrobial-related drug-drug interactions 15 CDC. Core Elements of Hospital Antibiotic Stewardship Programs. 2014.
- 17. Interventions: Infection/Syndrome Specific • Intended to improve prescribing for specific syndromes • Community-acquired pneumonia • Urinary tract infections • Skin and soft tissue infections • Empiric coverage of MRSA infections • Clostridium difficile infections • Treatment of culture-proven invasive infections • Should NOT interfere with prompt and effective treatment for severe infection or sepsis 16 CDC. Core Elements of Hospital Antibiotic Stewardship Programs. 2014.
- 18. Tracking • Monitor antibiotic use prescribing • Identify opportunities for improvement • Assess impact of efforts • Process measures • Antibiotic use • Controversy regarding best methods for monitoring use • DDD = defined daily dose • DOT = days of therapy • Outcomes measures 17 CDC. Core Elements of Hospital Antibiotic Stewardship Programs. 2014.
- 19. Reporting • Center for Medicare & Medicaid Services • Required • e.g. CLABSI, CAUTI, MRSA, Clostridium difficile infections • National Healthcare Safety Network (NHSN) • Not yet required, but encouraged • Provides a mechanism for facilities to report and analyze antimicrobial use and/or resistance over time at the facility and national levels • Somewhat complex requirements and setup outlined by CDC 18 CDC. Antimicrobial Use and Resistance (AUR) Module. 2017. CDC. Core Elements of Hospital Antibiotic Stewardship Programs. 2014.
- 20. Education • Provide regular updates on antimicrobial prescribing, antibiotic resistance, and infectious disease management • Address both national and local issues • Choose format based on receptiveness at your institution: • Didactic presentations • Posters, flyers, newsletters, emails • ASP website • Review de-identified cases where changes in antimicrobial therapy could have been made 19
- 21. 20 aimed.net. au
- 22. Antibiograms • Requirements • Compile annually • Include only the first isolate per patient • Collaborative effort • Limitations • MICs • Patient-specific factors (e.g. infection history, past antimicrobial use, comorbidities, age) • Single organism-antimicrobial combinations • Cross-resistance and synergy are not generally considered • Combination antibiograms • Generalizability 21 Pharmacotherapy. 2007;27(9):1306-1312. health.state.mn.us
- 23. Cultures Before Antimicrobials (if possible) • Improves the chances of identifying the offending microorganism • Administration of antimicrobials before culture collection may decrease culture yields • More difficult to deescalate therapy without cultures • DO NOT DELAY THERAPY! 22
- 24. Does That Drug Cover That Bug? • All parameters can be correct, but if the antimicrobial does not cover the causative pathogen, the patient is not likely to clear the infection • Select empiric therapy based on patient, disease, and institution-specific characteristics • Follow up on cultures and other diagnostic tests • Caution with polymicrobial infections 23
- 25. Infection vs. Contamination vs. Colonization • Infection – true positive from causative organisms • Contamination – false positive due to contaminate • Time to culture positivity • Number of positive blood bottles • Consider what sites should normally be sterile • Consider common causes of culture contamination • Question polymicrobial culture results • Promote correct antiseptic technique when obtaining cultures • Colonization – false positive due to pathogens that naturally occur at a specific site (e.g. anaerobes in the mouth) • Review other labs – WBC with differential, procalcitonin, fever curve, etc. • Consider the patient’s presentation 24
- 26. 25 Clin Infect Dis. 1997;24:584-602.
- 27. Duration, Duration, Duration! • Undertreating does not tend to be an issue • Overtreating with unnecessary extensions of antimicrobial regimens are not uncommon • Recommend durations based on published guidelines • e.g. – HAP duration is now 7 days • Encourage use of stop dates 26
- 28. Get to Know the Micro Lab • Provide timely, reliable, and reproducible identification and antimicrobial susceptibility results • Promptly report unusual patterns of resistance • Optimize communication of critical test result values and alert systems • Provide guidance for adequate collection of microbiology specimens • Provide, revise, and publicize annual antibiogram • Use cascade or selective reporting • Perform testing for susceptibility to new drugs • Broaden use of validated rapid diagnostic and rapid antimicrobial susceptibility testing 27 Clin Microbiol Rev. 2017;30:381-407.
- 29. Rapid Diagnostics • Ability to identify organisms quickly • Decrease diagnostic uncertainty • To be effective, rapid diagnostics should be tied to an ASP • Multiple rapid diagnostics available: • Multiplex PCR (bacterial and viral) • MALDI-TOF • Urinary antigens (Legionella, S. pneumoniae) 28
- 30. Selective Reporting • Antibiotic sensitivity results are restricted • Predefined antimicrobial susceptibilities are released based on the identified pathogen • Usually broad-spectrum antimicrobials would be hidden • Results available, but must be requested • Influences prescribing patterns • Encourages prescribers to utilize preferred, narrow-spectrum agents 29 Eur J Clin Microbiol Infect Dis. 2013;32(5):627-36.
- 31. Post ASP Implementation • Initially, resistance, prescribing patterns, and cost savings will likely improve dramatically • Improvements eventually stabilize • Continued decreases in antibiotic use and cost should not be expected • But, if programs are terminated, previous gains will begin to decline 30 CDC. Core Elements of Hospital Antibiotic Stewardship Programs. 2014. Infect Cont Hosp Epi. 2012;33(4):338-45.
- 32. Outpatient Antimicrobial Stewardship • ~60% of U.S. antibiotic expenditures for humans are related to care received in outpatient settings • ~20% of pediatric visits and ~10% of adult visits in outpatient settings result in an antibiotic prescription • In 2011, approximately one third of C. difficile infections in the U.S.were community-associated infections 31 CDC. Core Elements of Outpatient Antibiotic Stewardship. 2016.
- 33. 32 CDC. Core Elements of Outpatient Antibiotic Stewardship. 2016.
- 34. Outpatient Stewardship Interventions 33 JAPhA. 2017. Article in Press.
- 35. Common Mishaps • Rhinosinusitis • 98% are viral and antibiotics often do not help even when due to bacteria • Common cold • Over 200 viruses can cause the common cold • Pharyngitis • Only 5-10% are GAS (“strep throat”) • Uncomplicated UTI • Should not treat in absence of symptoms • Acute otitis media • Most common infection for pediatric antibiotic prescribing • Watchful waiting appropriate in many cases 34 cdc.gov/getsmart/community
- 36. The Role of the Outpatient Pharmacist • Educate patients and parents about properly taking antibiotics and the potential harms of antibiotic use, including antibiotic resistance and adverse drug events • Serve as the final healthcare provider to see a patient before an antibiotic is dispensed • Provide guidance for symptom relief for common infections which do not require an antibiotic • Promote available vaccines 35 cdc.gov/getsmart/community
- 37. The Role of the Pharmacy Technician • Identify recurring antimicrobial prescriptions for the same patient and inform the pharmacist • Screen patient’s for appropriate vaccinations • Inquire about allergies to antimicrobials • Assist with data collection and entry • Update educational materials/website 36
- 38. Spread the Word – Educate the Masses • Social media • Twitter, Facebook, etc. • CDC Get Smart • Patient and provider materials • Engage, educate, and empower! 37 cdc.gov/getsmart/community
- 39. Antimicrobial Stewardship Resources • CDC - Core Elements of Hospital ASPs • CDC - Core Elements of Outpatient Antibiotic Stewardship • IDSA guidelines – Implementing an ASP • ASP training programs • SIDP • MAD-ID • Institution specific ASPs or guidelines • Cleveland Clinic Foundation • John Hopkins Hospital • Nebraska Medical Center • University of California, San Francisco • ECHO – Antimicrobial Stewardship (launched on 6/16/17) • http://echo.unm.edu/nm-teleecho-clinics/antimicrob/ 38
- 40. Conclusions • Antimicrobial resistance is a major problem and ASPs are a major part of the solution • Learn the CDC core elements and understand how to employ them in your practice • Question as many aspects of antimicrobial prescriptions as possible • Utilize your resources, including other pharmacists and technicians • Educate others – the more people are aware of the problem, the more people available to fix it 39
- 41. 40 Thanks for your attention! nizarmuhammad432@gmail.com
Editor's Notes
- For the purpose of this talk, the focus will be on resistance in bacteria, however resistance is observed in all microroganisms including TB, HIV, and influenza Antimicrobial resistance occurs naturally over time, usually through genetic changes. However, the misuse and overuse of antimicrobials is accelerating this process. In many places, antibiotics are overused and misused in people and animals, and often given without professional oversight. Examples of misuse include when they are taken by people with viral infections like colds and flu, and when they are given as growth promoters in animals and fish.
- Penicillin, the first commercialized antibiotic, was discovered in 1928 by Alexander Fleming. While it wasn’t distributed among the general public until 1945, it was widely used in World War II for surgical and wound infections among the Allied Forces. It was hailed as a “miracle drug” and a future free of infectious diseases was considered. When Fleming won the Nobel Prize for his discovery, he warned of bacteria becoming resistant to penicillin in his acceptance speech.
- Treating infections of either pan-resistant or nearly pan-resistant gram-negative microorganisms is an increasingly common challenge in many hospitals Could be a topic all on its own – further adds to the present problem Reverse development of new antibiotics versus resistant bacteria. The abscissa shows a time bar. The ordinate shows blue bars that indicate the number of antibiotics launched in the depicted period; the red line shows the percentage of bacteria resistant against the last resort antibiotic vancomycin in US hospital intensive care units; the black line shows a moving average trend line of antibiotics launched in the depicted period. The number of antibiotic-resistant bacteria infections is increasing whereas the development of new antibiotics is constantly decreasing.
- The Joint Commission Elements of Performance outlined in the new AS standards are largely based on CDC Core Elements
- Leadership support is critical to the success of antibiotic stewardship programs Financial support greatly augments the capacity and impact of a stewardship program and stewardship programs will often pay for themselves, both through savings in both antibiotic expenditures and indirect costs.
- An antibiotic “time out” prompts a reassessment of the continuing need and choice of antibiotics when the clinical picture is clearer and more diagnostic information is available. All clinicians should perform a review of antibiotics 48 hours after antibiotics are initiated to answer these key questions: Does this patient have an infection that will respond to antibiotics? If so, is the patient on the right antibiotic(s), dose, and route of administration? Can a more targeted antibiotic be used to treat the infection (de-escalate)? How long should the patient receive the antibiotic(s)?
- Automatic changes from intravenous to oral antibiotic therapy in appropriate situations and for antibiotics with good absorption (e.g.,Fluoroquinolones, trimethoprim- sulfamethoxazole, linezolid, etc.),60, 61 which improves patient safety by reducing the need for intravenous access. Dose adjustments in cases of organ dysfunction (e.g. renal adjustment). Dose optimization including dose adjustments based on therapeutic drug monitoring, optimizing therapy for highly drug-resistant bacteria, achieving central nervous system penetration, extended-infusion administration of beta- lactams, etc. Automatic alerts in situations where therapy might be unnecessarily duplicative including simultaneous use of multiple agents with overlapping spectra e.g. anaerobic activity, atypical activity, Gram-negative activity and resistant Gram-positive activity. Time-sensitive automatic stop orders for specified antibiotic prescriptions, especially antibiotics administered for surgical prophylaxis.65 Detection and prevention of antibiotic-related drug- drug interactions e.g. interactions between some orally administered Fluoroquinolones and certain vitamins.
- Community-acquired pneumonia. Interventions for community-acquired pneumonia have focused on correcting recognized problems in therapy, including: improving diagnostic accuracy, tailoring of therapy to culture results and optimizing the duration of treatment to ensure compliance with guidelines.66–70 Urinary tract infections (UTIs). Many patients who get antibiotics for UTIs actually have asymptomatic bacteriuria and not infections.71, 72 Interventions for UTIs focus on avoiding unnecessary urine cultures and treatment of patients who are asymptomatic and ensuring that patients receive appropriate therapy based on local susceptibilities and for the recommended duration.73–77 Skin and soft tissue infections. Interventions for skin and soft tissue infections have focused on ensuring patients do not get antibiotics with overly broad spectra and ensuring the correct duration of treatment.60, 78, 79 Empiric coverage of methicillin-resistant Staphylococcus aureus (MRSA) infections. In many cases, therapy for MRSA can be stopped if the patient does not have an MRSA infection or changed to a beta-lactam if the cause is methicillin-sensitive Staphylococcus aureus.58, 80 Clostridium dif cile infections. Treatment guidelines for CDI urge providers to stop unnecessary antibiotics in all patients diagnosed with CDI, but this often does not occur.81–84 Reviewing antibiotics in patients with new diagnoses of CDI can identify opportunities to stop unnecessary antibiotics which improve the clinical response of CDI to treatment and reduces the risk of recurrence.82, 85 Treatment of culture proven invasive infections. Invasive infections (e.g. blood stream infections) present good opportunities for interventions to improve antibiotic use because they are easily identi ed from microbiology results. The culture and susceptibility testing often provides information needed to tailor antibiotics or discontinue them due to growth of contaminants.86
- Antibiotic use process measures: Examples include determining if prescribers have: accurately applied diagnostic criteria for infections; prescribed recommended agents for a particular indication; documented the indication and planned duration of antibiotic therapy; obtained cultures and relevant tests prior to treatment; and modified antibiotic choices appropriately to microbiological findings. Antibiotic use: (DDD) - This metric estimates antibiotic use in hospitals by aggregating the total number of grams of each antibiotic purchased, dispensed, or administered during a period of interest divided by the World Health Organization-assigned DDD. DOT is an aggregate sum of days for which any amount of a specific antimicrobial agent is administered or dispensed to a particular patient (numerator) divided by a standardized denominator (e.g., patient days, days present, or admissions).44, 89 If a patient is receiving two antibiotics for 10 days, the DOT numerator would be 20. Outcomes measures: The impact of stewardship interventions on resistance is best assessed when measurement is focused on pathogens that are recovered from patients after admission (when patients are under the influence of the stewardship interventions).
- Keep in mind that although certain metrics may not be required by CMS for reporting, your P&T, hospital administrators, and other members of the stewardship team will likely want to know this information.
- Education has been found to be most effective when paired with corresponding interventions and measurement of outcomes.6
- Antibiograms provide data on the collective susceptibility of major pathogens across relevant types of antibiotic, usually stratified by specimen source (urine, non-urine or bloodstream). Antibiograms help guide the clinician and pharmacist in selecting the best empiric antimicrobial treatment in the event of pending microbiology culture and susceptibility results.
- The Clinical and Laboratory Standards Institute (CLSI; formerly NCCLS) published guidelines for use when creating an antibiogram. CLSI guidelines recommend compiling the antibiogram at least annually, including only the first isolate per patient in the period analyzed, and including only organisms for which ≥30 isolates were tested in the period analyzed. Antibiograms are compiled mainly by microbiology laboratory technologists, but may be a collaborative effort involving the lab, pharmacy, infection preventionists, and clinicians. CLSI M39-A4 recommendations for CASRs Recommendation Analyze and present CASR at least annually Include only final, verified results Include only species with results for 30 isolates Include only diagnostic (not surveillance) isolates Eliminate duplicate isolates by including only first species’ isolate/patient/period of analysis Include only routinely tested agents Report % S and exclude % I For Streptococcus pneumoniae, report data for both meningitis and nonmeningitis breakpoints For viridans group streptococci, report both % S and % I For S. aureus, report % S for all isolates and MRSA subset
- Obtaining cultures after antimicro - bial therapy has been started can cause inconclusive results because organisms that would otherwise be detected may not necessarily grow after exposure to an antibiotic agent.
- Increase laboratory work but also prolong lengths of patient stay and increase the use of broad-spectrum antibiotics, with negative consequences for antibiotic resistance and patient morbidity The value of multiple cultures largely flows from probability considerations: Most institutions have contamination rates in the range of 3% per blood culture drawn. It follows, then, that the probability of recovering the same microorganism in 2 culture sets from a patient, and of that organism being a contaminant, is less than 1 in 1000 (0.03 x 0.03 = 0.0009). The clinician can be quite confident, then, that 2 out of 2 blood cultures positive with the same pathogen, even one that is commonly a contaminant, represents real disease, assuming that the 2 blood cultures were obtained from separate venipunctures or catheter draws.
- Microorganisms Isolated from Blood Categorized According to Clinical Significance.
- Invite to participate in antimicrobial stewardship committee
- After an initial period of marked costs savings, antibiotic use patterns and savings often stabilize, so continuous decreases in antibiotic use and cost should not be expected; however, it is important to continue support for stewardship to maintain gains as costs can increase if programs are terminated. Results. The utilization costs decreased from $44,181 per 1,000 patient-days at baseline prior to the full implementation of the program (FY 2001) to $23,933 (a 45.8% decrease) by the end of the program (FY 2008). There was a reduction of approximately $3 million within the first 3 years, much of which was the result of a decrease in the use of antifungal agents in the cancer center. After the program was discontinued at the end of FY 2008, antimicrobial costs increased from $23,933 to $31,653 per 1,000 patient-days, a 32.3% increase within 2 years that is equivalent to a $2 million increase for the medical center, mostly in the antibacterial category. Conclusions. The antimicrobial stewardship program, using an antimicrobial monitoring team, was extremely cost effective over this 7-year period.
- Approximately 60% of U.S. antibiotic expenditures for humans are related to care received in outpatient settings Approximately 20% of pediatric visits 12 and 10% of adult visits 3 in outpatient settings result in an antibiotic prescription
- primary care, medical and surgical specialties, emergency departments, retail health and urgent care settings, and dentistry, as well as community pharmacists, other health care professionals, hospital clinics, outpatient facilities, and health care systems involved in outpatient care
- outpatient AS initiatives can take on numerous forms; however, at the most basic level, all interventions are designed to affect a process on the patient-infection continuum When implementing a new AS initiative or expanding an existing ASP, the AS team should perform an evidence-based assessment of antibiotic prescribing for infectious diseases syndromes and identify barriers to optimal management across the patient-infection continuum.