Download Antimicrobial Stewardship in Long Term Care

Antimicrobial Stewardship in
Long Term Care
Shira Doron, MD
Assistant Professor of Medicine
Associate Hospital Epidemiologist
Tufts Medical Center
What is Antimicrobial Stewardship?
Antimicrobial stewardship involves the optimal
selection, dose and duration of an antibiotic
resulting in the cure or prevention of infection
with minimal unintended consequences to the
patient including emergence of resistance,
adverse drug events, and unnecessary costs.
Ultimate goal is improved patient care
and healthcare outcomes
Dellit TH, et al. CID 2007;44:159-77,
Hand K, et al. Hospital Pharmacist 2004;11:459-64
Paskovaty A, et al IJAA 2005;25:1-10
Infectious Diseases Expert Resources
Infectious Diseases
Specialists
Information
Infection Control
Technology
Specialists
Clinical
Pharmacists
Professionals
Antimicrobial
Stewardship
Clinical
Microbiologists
Hospitalist or
other clinician
Quality and Patient
Safety Staff
Infectious Diseases Trained
Pharmacists
Antimicrobial Stewardship Strategies
•
•
•
•
•
•
•
•
•
•
Prospective audit with intervention and feedback
“Front end”: Antimicrobial restriction and preauthorization
“Back end”: Prospective audits
Formulary restriction
Education, guidelines, clinical pathways
Dose optimization via PK-PD
De-escalation/Streamlining
Antimicrobial order forms/order sets if CPOE
IV-PO switch
Computerized decision support
Dellit TH, et al. CID 2007;44:159-77 Hand K, et al Hospital Pharmacist 2004;11:459-64
Paskovaty A, et al IJAA 2005;25:1-10
Stewardship in Long Term Acute
Care
Issues specific to LTACHs
• ID resources
– May not have full time ID physician
– Unlikely to have an ID pharmacist
• Moonlighters
– Tend to practice according to their “home” institution
• The antibiogram
– Combined resistance patterns of all of the referring
hospitals
• The formulary
– Must be able to accommodate the referred patient
New England Sinai Hospital
The program
• Worked with leadership, ID consultant, IP, Pharmacy
director
• End date and indication required by pharmacy for all
antimicrobials
• List of the “great eight” antimicrobials
• 2 ID physicians, off-site, M-F
• Log on and generate report: patients on antimicrobials
at least 7 days
• Review electronic medical records
• Recommendations made by email
• Clinical pathways
Results: Types of Infections April 2011 –
July 2012, n=530
Other
20%
Colitis
24%
Osteomyelitis
9%
Bacteremia
7%
UTI
14%
PNA
26%
12
Results: Types of Recommendations April
2011-July 2012
Other
8%
More Information
Needed
16%
Change
Antibiotics
6%
Stop Therapy
23%
Agree with
Management
47%
13
Results: Types of Antimicrobials, April
2011 – July 2012
Metronidazole
Piperacillin-Tazobactam
Linezolid
3rd and 4rth generation Cephalosporins
Carbapenems
Fluoroquinolones
Other
IV Vancomycin
PO Vancomycin
0
20
40
60
80
100
120
14
Results: NE Sinai Antimicrobial Usage
DDD/1000 patient days
Year Prior
DDD/1000 patient days
Year After
Fluoroquinolones
3.7
6.1
3rd and 4th generation
Cephalosporins
18.9
21.6
Carbapenems
30.9
31.3
Linezolid (PO and IV)
20.3
13.7
PO Vancomycin
49.1
18.4
PO Metronidazole
34.4
24.9
Medications
15
Stewardship in Long Term Care
• The challenges:
– Staffing
– Funding
– Buy-in
– Time
Simple things you can do
• Pick the low-hanging fruit
Guidelines/clinical pathways/order
forms
Education
Probiotics
• “Living microorganisms which upon ingestion in
certain numbers exert health benefits beyond
inherent general nutrition”
Can probiotics help prevent C.
diff from developing in patients
taking antibiotics?
• Cochrane systematic review 2013:
– 1871 studies, 31 met criteria to be included,
4492 subjects
– Probiotics reduced risk of C. diff associated
diarrhea by 64% (2% in probiotic group
versus 5.5% in placebo/no treatment group)
Goldenberg et al. Cochrane Database of Systematic
Reviews 2013, Issue 5.
Can probiotics help prevent C.
diff?
• Authors’ conclusions: “Based on this
systematic review andmeta-analysis of 23
randomized controlled trials including 4213
patients,moderate quality evidence
suggests that probiotics are both safe and
effective for preventing Clostridium
difficile-associated diarrhea.”
Can probiotics help prevent C.
diff?
• Caveat: each probiotic strain behaves
differently. One cannot extrapolate results
from a study using one strain to the
efficacy of another.
Probiotics
• Most common US probiotics:
– Lactobacillus acidophilus
– Lactobacillus GG (Culturelle®)
– Lactobacillus reuteri
– Bifidobacterium (various)
– Saccharomyces boulardii (Florastor®)
– Combination products (VSL#3®)