Prof -`con discussion during IFIC: costs versus antimicrobial resistance

1. 18-03-16
1
¤ none … but
I had nothing to do with what
happened to my last
Pro-Con debate oponent
¤ AMS - what is it about
¤ Why is Agnes wrong
¤ Why is it all about costs
An ongoing effort to opDmize anDmicrobial use
among hospitalized paDents in order to:
¤ Improve paDent outcomes
¤ Ensure cost-effecDve therapy
¤ Reduce adverse sequelae of anDmicrobial use
(one of which is anDmicrobial resistance)
MacDougal, Clin Microbiol Rev, 2005, 18:638-656
¤ Consults- ‘audit and feedback’
² Reserve anDbioDcs
² Risk-paDents
¤ RestricDng choices
² AnDbioDc guideline (adjusted CM reports and CP dispensing)
¤ Guideline development
² CAP
² UTI
¤ Projects to improve anDmicrobial use
² Switch program, 5S protocol
¤ EducaDon

2. 18-03-16
2
¤ Start: wrong indicaDon, not according to
guideline
¤ Switch iv to oral not done when possible
¤ Streamlining/adjustment according to
suscepDbility not done
¤ Safety – disregarding interacDons
¤ Stop – unneeded conDnuaDon
Let’s start the Pro-Con discussion on:
vs
Resistance Money !
… and some
help with
resistance
… have to
say that but
of course it’s
money
Resistance Cochrane review
¤ ‘Interven:ons to improve an:bio:c
prescribing in hospitals are succesful and
can help to reduce microbiological resistance’
¤ 3 controlled studies with regard to resistance:
² de Man 2000, Lancet (restricted to NICU)
² Singh 2000 AJRCC (automaDc stop of AB)
² Toltzis 2002 Pediatrics (cycling)
Brown, 2009, Cochrane library
Obviously not
“reduce”, but
prevent some
emergence
¤ In spite of the known
associaDon between
anDmicrobial use and
resistance, assuming that an
improvement in microbio-
logical outcomes from studies
that only demonstrate a
reducDon in anDmicrobial
usage is hazardous.
HAZARDOUS
CONCLUSIONS
There are other - probably even stronger – factors
with impact on resistance rates than changes in
absolute quanDDes of anDmicrobial drug use:
¤ Differences in potenDal for selecDon of
resistance between anDmicrobials
¤ Impact of duraDon of therapy and dosage
changes
¤ Secular trends in resistance
¤ Culture and liDgaDon, …

3. 18-03-16
3
Linear least-squares regression of changes in fluoroquinolone use
on the changes in proporDon of fluoroquinolone-resistant P.
aeruginosa in 19 hospitals between 2000 and 2003
Macdougall & Polk Clin Microbiol Review 2005
• Most hospitals increased quinolone use but only one had a
marked increase in rates of resistance (squared marker).
Macdougall & Polk Clin Microbiol Review 2005
Eight hospitals decreased fluoroquinolone use, but in only one
had an important decline in resistance (circled marker)
Macdougall & Polk Clin Microbiol Review 2005
These outlying observaDons may be more likely to be published
and would exaggerate the modest relaDonship between changes
in use and resistance noted across all hospitals.
Macdougall & Polk Clin Microbiol Review 2005
¤ Studies of the implementaDon of anDmicrobial
stewardship and its effects on resistance are extremely
difficult to control and are usually observaDonal.
¤ A systemaDc review of the literature ahempted to
idenDfy “rigorous evaluaDons” of intervenDons to
improve hospital prescribing of anDmicrobial drugs.
¤ Of the 16 studies that met criteria for inclusion, only 4
provided strong evidence that changes in prescribing
anDmicrobial drugs to hospital inpaDents can decrease
anDmicrobial resistance.
¤ Four studies were negaDve, and the 8 remaining studies
were cited as having flawed designs, allowing for
alternaDve explanaDons for the outcome.
Davey P et al. Emerg Infect Dis. 2006 Feb; 12(2):211-6.
Reducing
resistance
Saving
Money
Sorry,
wrong
picture
Hmm… at least it’s not
increasing resistance

4. 18-03-16
4
Reducing
resistance
Saving
Money
Obviously the organizers
let me go first for a reason:
They know that this is the
“pro” statement
Gougled it and found
nothing about saving
money !
The data I have seen are
biased or lies
Not one site men:oned “An:microbial Stewardship”
¤ yes, there might even be some (very lihle) bias
in studies showing cost-savings …
Agnes Andreas
¤ Sure, we needed them for our business case*
to create the A-team in our hospital
“business case in medicine” =
a well thought of and non-detectable sum of lies and
assumpDons to be able to finance what we believe is
needed for the safety of our paDents
¤ Sure, we needed them for our business case*
to create the A-team in our hospital
¤ Since the funding of many anDmicrobial
stewardship programs is conDngent upon
demonstraDon of cost-effecDveness programs
that do not achieve posiDve results may be
disconDnued.

5. 18-03-16
5
¤ PaDents receiving one of 10 target anDmicrobials for greater
than 3 days were randomized to the intervenDon arm or to
the standard of care.
¤ The intervenDon consisted of a having a clinical pharmacist
and infecDous diseases fellow review the medical records of
paDents receiving the target anDmicrobials. If there was
agreement on a need to opDmize anDmicrobial therapy
(changing or stopping therapy, switching to oral regimen, or
an alternaDve dosage), a nonpermanent chart note was
wrihen; 85% of suggesDons were implemented.
¤ There was no significant difference in clinical or microbiolog-
ical outcomes between the groups, but total anDmicrobial
costs were significantly lower in the intervenDon arm;
yearly savings were esDmated at $390,000
Fraser et al. Arch. Intern. Med 1997;157:1689–1694
¤ 275-bed community hospital randomized paDents receiving
potenDally inappropriate anDmicrobials to standard care or to
have a mulDdisciplinary team provide suggesDons for therapy
(67).
¤ Eighty-nine percent of suggesDons provided in the intervenDon
arm were accepted.
¤ The median length of stay was shorter by 3 days in the
intervenDon arm than the control arm, and an overall cost
reduc:on of $2,642 per intervenDon was esDmated.
¤ Other clinical and microbiologic outcomes were similar
between the two groups.
Gums et al. Pharmacotherapy 1999;19:1369
¤ Randomized inpaDent clinical services assigning to the
intervenDon arm and to the control arm.
¤ All orders for levofloxacin or cerazidime in the
intervenDon group were reviewed. If an order was not
in compliance with the guidelines, a member of the A-
team contacted the prescriber to suggest alternaDve
therapy.
¤ The duraDon of inappropriate therapy of the target
anDmicrobials was reduced by approximately 40% in
the intervenDon group, while clinical outcomes were
similar between the groups.
Solomon et al. Arch Intern Med 2001;161:1897
¤ Direct cost savings of approximately $8,000 could be ahributed to these
intervenDons alone, but greater savings due to reduced toxicity,
superinfecDons, and development of resistance are likely as well.
² Schentag et al
¤ Fewer anDmicrobials were used, the mean cost of anDmicrobials decreased,
fewer anDmicrobial-related adverse drug events occurred, and fewer
paDents were treated with a drug to which their infecDng organism was not
suscepDble.
² LaGer-Day Saints Hospital in Utah
¤ Studies have shown joint, infecDous-pharmacy programs for managing
anDmicrobial programs produce significant benefits in terms of both quality
of care and cost effecDveness.
² SHEA 0nline
hhp://www.cdc.gov/getsmart/healthcare/evidence/asp-int-costs.html
ConDnues for 7 pages

6. 18-03-16
6
PhamD
ClinMicro/ID
ICT
¤ Control/restricted use of reserve-anDbioDcs
¤ Select and measure local indicators for
adequate anDmicrobial use
¤ Standardize empiric treatment and enhance/
foster iv-oral switch.
¤ EducaDon and training with regard to
anDmicrobial use
¤ Define all paDents categories that need bed-
side ID consultaDon
¤ Real-Dme surveillance (including feedback) of
local resistance trends
¤ all-cause mortality
¤ infecDon-related mortality
¤ duraDon of hospitalizaDon
¤ rates of readmission
What would you choose to take home?
Why even debate!

7. 18-03-16
7
… thus it mut be about the first $48 million!
Cover slightly modified
Reducing
Resistance
(development)
Money saved
to invest in:
• A-team
• Patient safety
• Infection Control
Reducing
resistance
Saving
Money
It’s not only about saving
money and (partly) about
reducing resistance, it’s
mainly about adequate
and opDmal AB-treatment
Antimicrobial
Stewardship