CME Lecture on Antimicrobial Stewardship

1. ANTIMICROBIAL
STEWARDSHIP
TAHSEEN J. SIDDIQUI, MD
CHAIR, INFECTION CONTROL & DEPT. OF MEDICINE
NADIYAH CHAUDHARY, PHARMD, BCPS
CLINICAL PHARMACIST
ALEEM AZIZ, RPH, MS, MHA
DIRECTOR OF PHARMACY
APRIL 4TH 2019

2. Learning Objectives
At the conclusion of this activity participants should be able to:
• Recognize the importance and relevance of ‘Antimicrobial
Stewardship Program’ in order to prevent antimicrobial resistance,
contain the healthcare costs, and improve patient outcomes.
• Identify the core elements of stewardship programs and their
effective implementation at the healthcare institutions.
• Employ into their clinical practice the hospital-specific clinical
protocols/guidelines and antimicrobial recommendations in
compliance with the CMS/Joint Commission requirements.
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3. Antimicrobial
Stewardship
Program
Overview
3

4. Antimicrobial
Stewardship
Definitions
4
Antimicrobial Stewardship refers to coordinated
interventions designed to improve and measure
the appropriate use of antimicrobials by
promoting the selection of the optimal
antimicrobial drug regimens, doses, duration of
therapy, and route of administration.
The major objectives of antimicrobial
stewardship are to achieve optimal clinical
outcomes related to antimicrobial use, to
minimize toxicity and other adverse events, and
to limit the selection for antimicrobial resistant
strains.
Antimicrobial stewardship may also reduce
excessive costs attributable to suboptimal
antimicrobial use.

5. 5

6. Antimicrobial
Stewardship
Program
Purpose
6
Antibiotic resistance is a significant and progressively worsening
problem at healthcare facilities around the world.
Combined with the lack of new antimicrobial agents in the drug
development pipeline, this indicates that judicious antimicrobial
management is necessary to preserve the antibiotics currently
available.
Per the CDC 20-50% of antibiotics prescribed in US acute care
hospitals are unnecessary or inappropriate.
Stewardship programs involve consistent management of
antimicrobials in all healthcare settings as a fundamental step in
slowing resistance and improving patient health.
Per The Joint Commission “antimicrobial stewardship programs
can help prevent the development of multidrug resistant
organisms, and reduce unnecessary drug use and costs associated
with expensive, broad-spectrum therapies used to treat HAIs”.
CMS and TJC developed the antimicrobial stewardship standards
for hospitals

7. TJC and CMS Standards
1. Leaders establish antimicrobial stewardship as an
organizational priority.
• Accountability documents
• Budget plans
• Infection prevention plans
• Performance improvement plans
• Strategic plans
• Using the electronic health record to collect antimicrobial stewardship data
Effective January 1, 2017-Medication Management (MM) Standard MM.09.01.01
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Elements of Performance for MM.09.01.01

8. 2. The hospital’s antimicrobial stewardship program includes the
following core elements:
• Leadership commitment: Dedicating necessary human, financial, and information
technology resources.
• Accountability: Appointing a single leader responsible for program outcomes.
• Drug expertise: Appointing a single pharmacist leader responsible for working to
improve antibiotic use.
• Action: Implementing recommended actions, such as systemic evaluation of
ongoing treatment need, after a set period of initial treatment (for example,
“antibiotic time out” after 48 hours).
• Tracking: Monitoring the antimicrobial stewardship program, which may include
information on antibiotic prescribing and resistance patterns.
• Reporting: Regularly reporting information on the antimicrobial stewardship
program, which may include information on antibiotic use and resistance to doctors,
nurses, and relevant staff.
• Education: Educating practitioners, staff, and patients on the antimicrobial program,
which may include information about resistance and optimal prescribing.
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TJC and CMS Standards

9. TJC and CMS Standards
• The hospital’s antimicrobial stewardship program uses organization approved
multidisciplinary protocols (for example, policies and procedures).
• Antibiotic Formulary Restrictions
• Assessment of Appropriateness of Antibiotics for Community-Acquired
Pneumonia
• Assessment of Appropriateness of Antibiotics for Skin and Soft Tissue
Infections
• Assessment of Appropriateness of Antibiotics for Urinary Tract Infections
• Care of the Patient with Clostridium difficile (c.-diff)
• Guidelines for Antimicrobial Use in Adults
• Guidelines for Antimicrobial Use in Pediatrics
• Plan for Parenteral to Oral Antibiotic Conversion
• Preauthorization Requirements for Specific Antimicrobials
• Use of Prophylactic Antibiotics
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10. NAH Antimicrobial Stewardship Program
Core Elements
• Antibiotic Approvals/Restrictions.
• Post-prescribing review/follow-ups:
• Tailoring antibiotics to subsequent microbiology results
• Changing antibiotics from broad to narrower-spectrum (de-
escalation)
• Controlling/shortening duration of antibiotic therapy
• Adjusting antibiotic doses based on drug levels and end-organ
function
• Converting an antibiotic from an intravenous to oral
formulation
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11. Formulary Restrictions
Policy MM 336: Antibiotic Formulary Restrictions
• Overutilization of broad-spectrum antimicrobials is a significant
contributor to the development of antimicrobial resistance.
• Antibiotics restrictions
– Can lead to immediate and significant reductions in cost.
– May be beneficial as a part of a multifaceted response to a nosocomial
outbreak.
• Antibiotics restricted at NAH to infectious disease specialists:
– Colistimethate (Colistin )
– Daptomycin (Cubicin®)
– Linezolid (Zyvox®)
– Meropenem (Merrem®)
– Micafungin (Mycamine®)
– Tigecycline (Tygacil®)
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12. • If the restricted abx is ordered by a non-ID physician:
– The pharmacist review the Antimicrobial Usage Criteria (Cl. Indications)
– If the order meets the criteria, the order can be dispensed as written.
– If the order does not meet the criteria, the pharmacist will contact the
prescriber.
– Prescribers can then change therapy or consult ID.
– A 24-hour stop date will be placed on the order until reviewed by the ID
consultant.
• Data on restricted antibiotic use is tracked monthly and reported at
the Infection Control Committee.
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Policy MM 336: Antibiotic Formulary Restrictions
Formulary Restrictions
Policy MM 336: Antibiotic Formulary Restrictions

13. Antimicrobial Stewardship
Restricted ABX
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0
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20
30
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50
60
70
80
90
100
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140
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180
190
200
JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC JAN FEB
Colistin
Daptomycin
Linezolid
Meropenam
Micafungin

14. Controlling/Shortening Duration of
Antibiotic Therapy
• Longer durations, despite clinical improvement tend to:
- Promote superinfection with multi-drug resistant organisms
- Increase antibiotic drug costs.
- Increase the risk of drug toxicities/interactions.
- Without any additional clinical benefit to the patients.
• Automatic 7 day soft-stop on all antibiotic orders.
• Clinical Pharmacists perform daily reviews for patients who are receiving
antibiotics for appropriate duration of antibiotic therapy to assess for de-
escalation and discontinuation opportunities. (Provider’s notes/labs (PCT).
• Run daily reports of antimicrobial agents set to expire
• Physician are contacted to discuss if therapy should be continued (Pharmacy
interventions)
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15. De-escalation Therapy/Streamlining
• Pharmacists review microbiology data for de-escalation
• To identify patients whose antibiotic therapy does not “match” the
reported microbiologic susceptibilities of the patients’ organisms
(“bug-drug mismatch”) and recommend an effective/appropriate
alternate to the physician.
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16. Tracking Trends
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Month Appropriate use Followed policy Ordered by ID
physician
November 2018 23/28 (82%) 21/28 (75%) 20/28 (71%)
December 2018 9/9 (100%) 7/9 (77%) 7/9 (77%)
January 2019 17/18 (94%) 17/18 (94%) 16/18 (88%)
February 2019 7/7 (100%) 6/7 (85%) 5/7 (71%)

17. Duplicate therapy
• Patients may unnecessarily receive multiple antibiotics that cover
the same organisms.
• For instance, a patient may be treated with piperacillin/tazobactam
(Zosyn)+ metronidazole for an intra-abdominal infection where
the metronidazole is added for a perceived benefit against
anaerobic organisms. Treatment with both of these agents is not
necessary.
• Similarly, linezolid may be added to vancomycin therapy to cover
vancomycin-resistant gram-positive organisms where the linezolid
alone is sufficient in most cases.
• Pharmacists review these cases and suggest the discontinuation of
one of the duplicate/redundant antibiotics.
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18. Importance of IV to PO conversion
• Benefits of IV to PO conversion include:
– Improved patient comfort and mobility
– Reduced exposure to nosocomial pathogens through the IV site
– Decreased risk of phlebitis
– Reduction in preparation and administration time
– Decreased hospital length of stay
– Decrease in costs
• Drug costs
• Supplies (IV tubing, syringes, IV pumps)
• Time (pharmacy and nursing)
• It’s an upcoming CMS requirement
3 1. C.2.e The facility has a system in place to identify patients currently receiving intravenous
antibiotics who might be eligible to receive oral antibiotic treatment.
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19. IV to PO conversion an NAH
• A process of reviewing patients on select IV antibiotics to assess
eligibility for conversion to PO
• Pharmacists review all patients on IV medications to evaluate
appropriateness to convert to PO.
• An assessment is documented in the patient’s EHR of inclusion
and exclusion criteria (approved by P&T)
• If the patient meets all inclusion criteria, the pharmacist generate
an order “per protocol” for the oral medication.
• Select medications with similar bioavailability are listed in the
policy with IV to PO conversion equivalents.
• Pharmacists can recommend conversion of other agents not
included in the protocol to the prescribing doctor.

20. Pharmacokinetics (PK) Service
• Diligence in therapeutic drug monitoring is especially important to
avoid toxicity and maximize efficacy.
• Unnecessary costs may accrue due to inappropriate number of
drug levels ordered and potentially increased hospital length of
stay due to over- or under-dosing.
• Antibiotics such as vancomycin and aminoglycosides are
challenging to dose and require adjustment based on renal
function, weight, volume of distribution, age, and other factors.
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21. • Clinical pharmacists monitor all patients receiving vancomycin
and aminoglycoside therapy including:
– Baseline and daily BUN/SCr ordered by “per protocol”
– Determine and order initial regimens
– Monitor daily weights for potential changes in doses
– Drug level ordering and monitoring “per protocol”
– Modify regimens based on changes in clinical status and/or levels
• Pharmacists complete daily assessments which are documented in
the patient’s EHR
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Policy MM 343: Pharmacokinetic Dosing Policy and Protocol
Pharmacokinetics (PK) Service

22. ANTIBIOGRAM
&
ANTIMICROBIAL
RECOMMENDATIONS
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23. 4/15/2019 23

24. 24

25. 25

26. 4/15/2019 26

27. Antimicrobial Stewardship
Recent Developments
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Changes in resistance patterns
– Increasing resistance to FQ with uropathogens (UTI)
– Increasing resistance to sulfamethoxazole-TMP with uropathogens
Empiric antibiotic updates
• Piperacillin-tazobactam (Zosyn) dosing updated from traditional to EID
• Cystitis
– Beta-lactams removed for empiric use due to inferior efficacy and increased AE
– Removed IV ciprofloxacin (NF)
• Cryptococcal meningitis
– Added induction treatment doses for fluconazole
– Added consolidation treatment doses for fluconazole
• C. diff Infection (CDI) recommendations updated
– Criteria from mild, moderate, severe to initial and fulminant
– Vancomycin PO is now recommended first-line

28. Reduction of Clostridium difficile Infections
Through Antimicrobial Stewardship
• Clostridium difficile infection (C. difficile) is a serious public health
problem that has recently increased in both incidence and
severity
• Antimicrobial stewardship targeted to C. difficile reduction shows
promise, because increased rates of C. difficile are associated
with inappropriate antibiotic use.
4/15/2019 28

29. 29

30. Antimicrobial Utilization Trends
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Name of Drugs JAN FEB MAR APR TOTAL
Zosyn 1072 726 982 2780
Cefipime 76 46 1 123
Ceftriaxone 147 210 248 605
Unysyn 8 12 2 22
Aztreonam 38 79 140 257
Meropanam 204 84 80 368
Azithromycin 39 57 36 132
Deptomycin 14 0 0 14
Tigecycline 0 0 2 2
Vancomycin 381 217 328 926
Linezolid 26 5 21 52
Colistin 0 0 21 21
Micafungin 0 0 5 5
Levofloxacin 81 57 92 230
Metronidazole 115 46 29 190
TOTA Doses= 2201 1539 1987 5727
Broad Spectrum Antibiotics Data 2019

31. Antimicrobial Stewardship
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0.00
1.00
2.00
3.00
4.00
5.00
6.00
JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC JAN FEB
Total ABX Cost /APD
0.00
0.10
0.20
0.30
0.40
0.50
0.60
0.70
0.80
0.90
JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC JAN FEB
Total ABX Doses/ APD

32. SUMMARY
• An antimicrobial stewardship program (ASP) is a systematic approach to
developing coordinated interventions to reduce overuse and inappropriate
selection of antibiotics, and to achieve optimal outcomes for patients in cost-
efficient ways.
• Pharmacists
– Perform daily monitoring for appropriateness
– Convert medications from IV to oral
– Review microbiology data for de-escalation
– Assist in PK dosing/ Renally dose adjust medications/
• Infection Control
– Tracks for newly emerging gram-negative resistance patterns
– Analyzes and report HAIs
– Promotes hand hygiene
– Perform periodic DUEs (Drug use evaluations)
– Reviews the annual antibiogram
– Incorporate stewardship activities
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