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3/4/2015 SCSHP 2015 Annual Meeting Antimicrobial Stewardship in An Era of Interdisciplinary Collaboration Eddie Grace, Pharm.D., BCPS(AQ‐ID), AAHIVP Associate Professor of Infectious Diseases Presbyterian College School of Pharmacy Definition • Antimicrobial stewardship is defined as a rational, systematic approach to the use of antimicrobial agents in order to achieve optimal outcomes. This means using the most appropriate agent, at the correct dose, for the appropriate duration in order to cure or prevent infection, while minimizing toxicity and emergence of resistance. Dellit TH, et al. Clin Infect Dis. (2007) 44 (2): 159-177. Disclosure Primary Goal • I do not have a vested interest in or affiliation with any corporate organization offering financial support or grant monies for this continuing education activity, or any affiliation with an organization whose philosophy could potentially bias my presentation • The primary goal of an ASP is to: • Optimize clinical outcomes while minimizing unintended consequences of antimicrobial use • Unintended consequences include the following: • Toxicity • The selection of pathogenic organisms such as Clostridium difficile • The emergence of resistant organisms (ESBLs, MRSA, VRE, pseudomonas) • Enhance patient safety Dellit TH, et al. Clin Infect Dis. (2007) 44 (2): 159-177. Objectives • By the end of the presentation, the audience should be able to: • List the core strategies required in an antimicrobial stewardship program • Recognize the significance of interdisciplinary collaboration among ASP members • Understand the importance of intra‐disciplinary collaboration within the pharmacy service for a successful ASP • Create a framework for starting or improving an ASP Secondary goal • One must note that although cost is important to any healthcare institution, the focus of antimicrobial stewardship program is the improvement of patient and public health • To reduce healthcare costs without adversely impacting the quality of care Dellit TH, et al. Clin Infect Dis. (2007) 44 (2): 159-177. 1 3/4/2015 Core Strategies of an ASP Supplemental Strategies • Based on the IDSA guidelines, there are two core strategies to an ASP : • • • • • • • 1. Prospective audit with intervention and feedback 2. Formulary restriction and preauthorization requirements for specific agents Education (with active intervention) Guidelines and Clinical Pathways Antimicrobial Cycling Combination therapy Streamlining/De‐escalation of therapy Conversion from IV to PO Dose Optimization Note: neither of these strategies are mutually exclusive Dellit TH, et al. Clin Infect Dis. (2007) 44 (2): 159-177. Core Strategy #1 Prospective Audit with Intervention and Feedback • Provide targeted feedback to prescribers based on the results of prospective audits • Can be performed by either an infectious disease physician or clinical pharmacist can result in reduced inappropriate use of antimicrobials • Collaboration between prescribers, infectious disease, micro, and pharmacy Dellit TH, et al. Clin Infect Dis. (2007) 44 (2): 159-177. Core Strategy #2 Formulary Restriction and Preauthorization • Includes one or more of the following methods: • Formulary based restriction • Medication only available to a certain service • Pre‐authorization based restriction Dellit TH, et al. Clin Infect Dis. (2007) 44 (2): 159-177. Supplemental Strategies Education • Education is considered to be an essential element of any ASP • Designed to influence prescribing behavior • Education to prescribers, pharmacists, and other clinical staff • Education alone without incorporation of active intervention is only marginally effective Dellit TH, et al. Clin Infect Dis. (2007) 44 (2): 159-177. Supplemental Strategies Guidelines and Clinical Pathways • Multidisciplinary development of evidence‐ based practice guidelines • Incorporating local microbiology and resistance patterns • Incorporation of current clinical guidelines • Medication is only available after approval by a certain team/group • Criteria based restriction • Medication is available if criteria for use is/are met • Criteria based on the national VA criteria for use • If criteria not met, prescriber can discuss with ASP for approval Dellit TH, et al. Clin Infect Dis. (2007) 44 (2): 159-177. Dellit TH, et al. Clin Infect Dis. (2007) 44 (2): 159-177. 2 3/4/2015 Supplemental Strategies Cycling Antibiotics • Currently there is insufficient evidence to support cycling antimicrobials Supplemental Strategies Conversion of IV to PO • A systemic plan for IV to PO conversion of antimicrobials with excellent bioavailability when the patient’s condition allows • This can decrease the length of stay and thus decrease the cost of healthcare • Examples: • Metronidazole, ciprofloxacin, clindamycin, fluconazole, voriconazole, linezolid Dellit TH, et al. Clin Infect Dis. (2007) 44 (2): 159-177. Supplemental Strategies Combination Therapy • There are insufficient data to recommend the routine use of combination therapy to prevent the emergence of resistance • Combination therapy does a role in certain scenarios Dellit TH, et al. Clin Infect Dis. (2007) 44 (2): 159-177. Dellit TH, et al. Clin Infect Dis. (2007) 44 (2): 159-177. Supplemental Strategies Dose Optimization • Dose adjustments based on: • • • • • • Changes in renal/hepatic function Indication/Location of infection MIC reported by microbiology Interactions with other medications Suspected/Identified Organism Antibiotic levels (e.g. vancomycin , and aminoglycosides Dellit TH, et al. Clin Infect Dis. (2007) 44 (2): 159-177. Supplemental Strategies Streamlining/De‐escalation of therapy • Goal is to streamline therapy (use a more narrow spectrum agent) based on C&S results which become available • Prevention of duplicative therapy on a patient when double‐coverage is not indicated/ intended • Discontinuation of therapy based on negative C&S results and lack of supporting clinical s/sx of infection Members of a Successful Antimicrobial Stewardship Program Dellit TH, et al. Clin Infect Dis. (2007) 44 (2): 159-177. 3 3/4/2015 Antimicrobial Stewardship Pharmacist Antimicrobial Stewardship Pharmacist • As a clinical pharmacist, it is recommended that the AS‐Pharmacist have the following qualifications: • There are two certificate programs for ID pharmacist training which include: • Licensed pharmacist • Advanced specialized education and training • Competent to practice in a team‐based direct patient care environment • Accredited residency training or equivalent post licensure experience is required • Board certification is required once the pharmacist meets the eligibility criteria by BPS ACCP. Pharmacotherapy 2014;34(8):794-797 Antimicrobial Stewardship Pharmacist • Knowledge and Skills needed by a AS‐ Pharmacist: • • • • General principles of antimicrobial stewardship Approaches to stewardship interventions Antimicrobials Microbiology and laboratory diagnostics Cosgrove SE, et al. Infect Contr Hosp Epi 2014;35(12): 1444-1450 Antimicrobial Stewardship Pharmacist • • • • • Common infectious syndromes Measurement and analysis of outcomes Informatics Program building and leadership Infection Control • Society of Infectious Diseases Pharmacists (SIDP) • http://www.sidp.org/page‐1442823 • $750 Phase 1: Self‐study learning component (20 hours or 2.0 CEUs). Please view our demonstration showing the style of the Self‐study component. Phase 2: Live webinars (6‐9 hours or 0.6‐0.9 CEUs) Phase 3: Skills component completed in the practice setting (10 hours or 1.0 CEU) Crader MF. Hosp Pharm 2014;49(1):32-41 Antimicrobial Stewardship Pharmacist • Making A Difference in Infectious Diseases (MAD‐ID) • http://mad‐id.org/antimicrobial‐stewardship‐ programs/ • Divided into two programs: Basic and advanced • Each program has a self‐study portion, online portion and practical exercise portion Stewardship pre‐requisite on‐line training (Part 1) $250.00 (for basic course) Live and practical components only (Parts 2 and 3) $250.00 (for basic course) Entire program (All 3 components, parts 1‐ 3) $500.00 (for basic course) Registration Fee (2015); paid when registering for annual meeting $350.00 (for advanced course) Collaboration • Two Types of collaboration are needed for a successful ASP: • Intra‐departmental collaboration • Inter‐departmental collaboration Cosgrove SE, et al. Infect Contr Hosp Epi 2014;35(12): 1444-1450 4 3/4/2015 Intradepartmental Collaboration Interdepartmental Collaboration • Intradepartmental collaboration can be divided into two types: • Collaboration between the following is need to create a core ASP committee: • Collaboration of the director of pharmacy with the ASP/ID pharmacists • Collaboration between the ASP/ID, clinical, and staff pharmacists • • • • • AS‐Pharmacist Infectious Diseases Physician Clinical Microbiologist Infection Control Specialist IT support Intradepartmental Collaboration Collaboration with Infectious Diseases Physicians • Collaboration of the director of pharmacy with the ASP/ID pharmacists • 86% of hospitals with an active ASP have an ID consultation service present • 63% of hospitals without an ASP have an ID consultation service present • Hospitals with a private independent ID service are 50% less likely to have an ASP than hospitals with a intrinsic ID service • The ASP pharmacist needs to be supported by the director of pharmacy by: • Providing adequate time to perform daily ASP • Providing authority to conduct interventions • Providing the authority to train staff on conducting ASP interventions • Granting authority to approve/deny restricted anti‐ infective requests Doron S, et al. Clin Ther 2013;35:758-765 Intradepartmental Collaboration Collaboration with Infectious Diseases Physicians • Collaboration between the ASP/ID, clinical, and staff pharmacists entails: • Barriers: • Educating and training all pharmacists to ensure a universal understanding of the basics of infectious diseases • Educating and training all pharmacists on the goals of the ASP and how these goals can be met • The ASP pharmacists working with the other pharmacists to prevent doubling of workload • • • • • Lack of ID specialist in the area/town Time constraints Cost of service Decrease in ID consults Perception among other physicians Crader MF. Hosp Pharm 2014;49(1):32-41 5 3/4/2015 Collaboration with Infectious Diseases Physicians Collaboration Infection Control Specialist • Overcoming Barriers: • An infection control specialist can assist the ASP by: • Increased number of ID consultations has been associated with ASP activity • Decreased time lapse to ID consultations (decreased 30‐day mortality rate) • Decreasing resistance translates into better patient care and outcomes • Providing up to date information on outbreaks • Providing recommendations to decrease MDRO transmission among patients • Provide epidemiological data on MDROs • Assist AS‐Pharmacist and ID‐physician in ensuring that ASP recommendations are being followed by other clinicians Morrill HJ, et al. Antimicrobial Resistance and Infection Control 2014;3:12-13 Collaboration with Infectious Diseases Physicians Collaboration IT • The AS‐pharmacist can support the ID‐ physician by: • In the era of electronic medical charts, IT can support the ASP by: • Recommending ID consults to other physicians when needed • Decreased workload by intervening on medication based questions • Continued follow up of patients after ID‐consults • Ensuring ID consult recommendations are followed as outlined by ID‐physicians • Providing continuous reports on patients on antimicrobials, organisms identified within the facility, and antibiotic use • Implementing clinical pathways created by the ASP into the medical chart • Monitoring use of clinical pathways and antimicrobial orders • Providing interval reports on pharmacy, microbiology, and infection control data Collaboration with the Clinical Microbiologist Conclusion • A clinical microbiologist is an essential to an ASP by: • ASP are a collaborative team effort including pharmacists, physicians, microbiologists, infection control specialists, and IT specialists • Collaboration among the pharmacists is also an essential component of success of an ASP • ASP goals and objectives need to be clearly defined • ASP goals should be measured on a regular basis • ASP is never the same in two different places • Creating antibiograms • Using newer diagnostic technology to identify infections more rapidly • Provide additional testing if needed for certain antimicrobials • Selection of the microdilution cards to ensure clinical relevance 6 3/4/2015 Thank You for Your Attention 7
