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Transcript
Antimicrobial Stewardship: Why and How John Lynch, MD, MPH University of Washington & Harborview Medical Center Disclosure Consult for the Washington State Hospitalization Association on HAIs and antimicrobial stewardship “Pitted against microbial genes, we have mainly our wits” - Joshua Lederberg,PhD, 1958 C. difficile infection 50% Adverse effects Drug resistance Increased cost Less C. difficile 50% Fewer AEs Slow down MDRs Decrease cost Stages of an Ideal Scenario for Treatment of Infection • Initial, broad-spectrum antimicrobial therapy is selected • Sensitive means to identify pathogenic organism are used • Reliable susceptibility result is rapidly achieved • Antimicrobial therapy is modified • Antimicrobial therapy is discontinued Pseudomonas aeruginosa Escherichia coli MOA ESBL KPC NDM-1 Chromoso me/Plasmid Plasmid Plasmid Plasmid SPICEM E.coli, Klebsiella Klebsiella, enterobacteriaceae Klebsiella, enterobacteriaceae 1 gen Ceph R R R R 2 gen Ceph R S R/S R 3 gen Ceph R R R R 4 gen Ceph S R/S R R Cefotax + Clav R S R R Carbapenem S S R R Location Bugs AmpC The Apocalypse Pig…. - First description of a plasmid-mediated polymixin resistance mechanism (MCR-1) - Found on animal meat and in human infection samples - In December, also reported in Denmark Liu, Lancet ID, Nov 2015 The Apocalypse Pig…. - First description of a plasmid-mediated polymixin resistance mechanism (MCR-1) - Found on animal meat and in human infection samples - In December, also reported in Denmark Liu, Lancet ID, Nov 2015 Tip of the Iceberg? 760 Cases of VRE identified between Jan 1997 – Oct 1999 Percent of Cases Identified 100 90 80 70 60 50 40 30 20 10 0 86% undetected by clinical specimen alone Clinical Culture Surveillance Surveillance, then Clinical Culture Clin Infect Dis Goossens, Lancet, 2005 Unnecessary Antibiotic Use Shaughnessy ICHE 2012 Reasons for Antibiotic Use Shaughnessy ICHE 2012 Estimated U.S. Burden of Clostridium difficile Infection (CDI), According to the Location of Stool Collection and Inpatient Health Care Exposure, 2011. Lessa FC et al. N Engl J Med 2015;372:825-834. More numbers on antimicrobial problems… • 2 million people per year in the US are infected with bacteria with some level of resistance • At least 23,000 people die as a direct result • 250,000 people are hospitalized for Clostridium difficile infections per year • Around 14,000 people die due to C. difficile per year • Excess costs: ~$20 billion direct + ~$35 billion indirect per year CDC Antibiotic Resistance Threats in the United States, 2013 CDC (2008) • Antibiotics are misused in hospitals • Antibiotic misuse adversely impacts both patients and society • Improving antibiotic use improves patient outcomes and saves money • Improving antibiotic use is a public health imperative What is Stewardship? “…the conducting, supervising, or managing of something, especially, the careful and responsible management of something entrusted to one’s care” “The moral and ethical responsibility for caretaking on behalf of others” Dr. John Pauk Antimicrobial Stewardship • Timely antimicrobial management • Appropriate selection of antimicrobials • Appropriate administration and deescalation of antimicrobials • Use of expertise and resources at point of care • Continuous and transparent monitoring of antimicrobial use = right drug, right dose, right time, right duration Pending CMS Requirement Antimicrobial Stewardship Strategies •Educational/guidelines •Formulary/restriction •Review and feedback •Computer assistance “Minimum Requirements” • Creation of a multidisciplinary interprofessional AS team • Formulary restriction (?) • Develop institutional clinical guidelines • Stewardship interventions to detect and eliminate unnecessary or inappropriate antimicrobial use • Process to measure and monitor antimicrobial use • Periodic distribution of facility-specific antibiogram Dellit, ICHE 2007 CDC Core Elements • • • • • • • Leadership commitment Accountability Drug expertise Action Tracking Reporting Education Antimicrobial Stewardship in Action New Drugs and Vaccines Improved Diagnostics Reduced Resistance Reservoirs Education Infection Control Benchmarks Adapted from Fishman, Am J Med, 2006 The Stewardship Team We may run the ASP, but everyone who pays for, takes, orders, reviews, fills, delivers, and administers is an antimicrobial steward. Prescribing clinicians - Follow site specific guidelines where possible or other guidelines - Differentiate between true MDRO risk and being “really sick” - De-escalate antibiotics ASAP based on data - Listen to the team clinical pharmacist Non-prescribers - Pharmacists have to be leaders and content experts on antimicrobials, have to be able to interpret micro data and de-escalate - Microbiologists need to produce timely results and have to explore newer technologies with quicker turn around times - Infection control practitioners should provide quality surveillance data - Administrators must recognize the value of great pharmacists, microbiologists, and ICPs, and support their participation in the ASP Antibiotic Prescribing Behavior (etiquette) The APB of healthcare professionals is governed by a set of cultural rules. Antimicrobial prescribing is performed in an environment where the behavior of clinical leaders or seniors influences practice of junior doctors. Senior doctors consider themselves exempt from following policy and practice within a culture of perceived autonomous decision making that relies more on personal knowledge and experience than formal policy. Prescribers identify with the clinical groups in which they work and adjust their APB according to the prevailing practice within these groups. A culture of “noninterference” in the antimicrobial prescribing practice of peers prevents intervention into prescribing of colleagues. These sets of cultural rules demonstrate the existence of a “prescribing etiquette,” which dominates the APB of healthcare professionals. Prescribing etiquette creates an environment in which professional hierarchy and clinical groups act as key determinants of APB. Chirani, Clin Infec Dis, 2013 ASP @ Harborview Medical Center • 413 bed county hospital • Teaching hospital for UW • Level 1 trauma/burn center for WWAMI • Beds: 61 psych, 29 rehab, 89 ICU • >60,000 ER visits/year HMC AS Program Origin Where we were… • 2000 = no program • 2001 AS introduced as Process Improvement project • Lots of linezolid and imipenem use, CA-MRSA explosion • 2003 - one ID physician and one ID pharmacist approved • Daily review of cases collected by ID pharmacist • No restrictions on antibiotic use • Tracking of total antibiotic costs, days of hospitalization, PICC lines* used, savings vs FTE • IV to PO conversions • Joint UWMC, SCCA, HMC P&T Committee • Development of VAP guidelines • 2 years of monthly meetings to review finances HMC AS Program Evolution Integration with Infection Prevention/QI • Decision support software (TheraDoc and Amalga) • Use of surveillance data to focus efforts and for feedback to clinicians • Quality improvement and patient safety effort • Surgical Care Improvement Program/SCOAP Frontlines • Stewardship program relies on 2 channels: • Clinician-to-Clinician • Pharmacist-to-Pharmacist • Guideline and order set review • CPOE • Service-oriented resource for any antibiotic questions HMC AS Program Today • Review of cases reported clinical pharmacists • bug-drug mismatches • potential de-escalation interventions • overlapping antibiotic coverage • dosing • IV-to-PO conversion • Review of surveillance alerts • Discussion of complex interventions and challenges to intervention addressed as a team • Review of antibiogram • Collection of antibiotic costs • Guidelines, clinical pathways, CPOE review • Leadership of ID P&T committee UW P&T Committee- Dosing Piperacillin/Tazobactam prolonged infusion Usual dosing is over 30 minutes every 6 hours • Studies of prolonged infusion – same dose over 4 hours every 8 hours – support similar outcomes in critically ill patients • Cuts daily drug amount by 25% • Challenges: need a line for infusion 12 hours of the day so RN education and buy-in is critical • Savings >$30,000 • VAP Prevention 2003-2004 VAP Prevention 2004-2010 VAP Pathogens 2003 Microorganism Early Onset (N=30) Late Onset (N=138) MSSA 8 (27%) 21 (15%) Haemophilus 8 (27%) 20 (14%) Strep pneumoniae 6 (20%) 1 (0.7%) Alpha heme strep 5 (17%) 20 (14%) MRSA 3 (10%) 32 (23%) Acinetobacter 3 (10%) 44 (32%) Enterobacter 2 (7%) 4 (3%) Pseudomonas 0 (0%) 13 (9%) Late VAP- Yes Change! Discontinuing Routine EVD Prophylaxis Patients with EVD 2011 2012 Positive CSF Culture 12.8% (45/352) 10.3% (38/369) Percent with C. difficile 5.4% (19/352) 2.4% (9/369) 2011 2012 C. difficile Cases Rate per 1000 ptdays C. difficile Cases Rate per 1000 ptdays Neurosurgery Service 20 1.18 10 0.55 NICU 19 1.97 5 0.51 Antibiotic Susceptibility Overview This chart is intended as an initial guidance, and should not replace clinical judgement Gram Postive Cocci VRE Gram Negative Bacilli Enterococcus E. coli, Proteus fecalis MRSA MSSA Streptococci Klebsiella mirabilis Nafcillin, Dicloxacillin Penicillin Amoxicillin Amoxicillin Cefazolin, Cephalexin Pseudomonas Acinetobacter CEHMPS Clindamycin (above diaphragm) Metronidazole (below diaphragm) Clindamycin Rifampin Linezolid, Daptomycin Vancomycin, Linezolid, Daptomycin TMP/SMX Amp/sulbactam Amox/clavulan Piperacillin/ tazobactam Anaerobes TMP/SMX Ciprofloxacin Levofloxacin Ciprofloxacin Levofloxacin Moxifloxacin Moxifloxacin Cefotaxime, Ceftriaxone, Cefuroxime Ceftazidime Cefepime Ampicillin/sulbactam, Amoxicillin/clavulanate (only anaerobes above diaphragm) Amp/sulbactam, Amox/clavulanate Piperacillin/ tazobactam Piperacillin/tazobactam Meropenem Imipenem Imipenem Ertapenem Gentamicin Ertapenem Gentamicin, Tobramycin, Amikacin Aztreonam Aztreonam CEHMPS = Citrobacter freundii, Enterobacter spp., Hafnia alvei, Morganella spp., Providencia spp., Serratia spp. CEHMPS may harbor AmpC inducile beta lactamases. Resistance to penicillins and 3rd generation cephalosporins may arise on therapy. TMP/SMX = trimethoprim/sulfamethoxazole, VRE = vancomycin resistant enterococci Based on 2015 UW Medicine antibiogram, highlighted if suceptibility >70% ASPs and Technology On the Near Horizon…. •Tele-stewardship (UW TASP) •NHSN AUR reporting On the Not So Far Horizon…. •Antibiotic indications and time-outs • Technical (EHRs in transition) and safety? •“Gold-standard” prospective audit and feedback • Challenging with rotating trainees • Not enough FTE •Conflicts with CMS sepsis requirements? Thanks to… Jeannie Chan, PharmD, MPH (HMC) Tim Dellit, MD (HMC) Rupali Jain, PharmD (UWMC) Paul Pottinger, MD (UWMC) The Antimicrobial Stewardship Consortium of Washington ([email protected])