9/21/2017 Antimicrobial Stewardship JONATHAN PERDUE, PHARMD PGY1 PHARMACY RESIDENT ST. CLAIRE REGIONAL MEDICAL CENTER 09/23/2017 1 Disclosure This speaker has no actual or potential conflicts of interest related to this presentation 2 Objectives • Define antimicrobial stewardship • Describe different antimicrobial stewardship initiatives • Discuss literature demonstrating the impact of different antimicrobial stewardship initiatives 3 1
9/21/2017 What is Antimicrobial Stewardship? • Antimicrobial stewardship is defined in a consensus statement by the Society for Healthcare Epidemiology of American (SHEA), Infectious Diseases Society of America (IDSA), and Pediatric Infectious Diseases Society (PIDS) as: • “Coordinated interventions designed to improve and measure the appropriate use of antimicrobial agents by promoting the selection of the optimal antimicrobial drug regimen including dosing, duration of therapy, and route of administration.” Fishman N. Infect Control Hosp Epidemiol . 2012; 33: 322–7. 4 Why is Antimicrobial Stewardship Important? • Between 20% and 50% of all antibiotics prescribed are inappropriate • Antibiotic resistance is increasing • Few new antibiotics are being developed • Nearly 20 antibiotics were introduced from 1980 ‐ 1984 • About 10 were introduced in the past decade • Joint Commission Standard CDC. Antibiotic Resistant Threats in the United States, 2013. 5 The Joint Commission. Jt Comm Perspect. July 2016; 36(7): 1, 3 ‐ 4, 8. Antibiotic Prescriptions by State 529 ‐ 656 689 ‐ 774 780 ‐ 836 843 ‐ 896 899 ‐ 972 996 ‐ 1237 CDC. Antibiotic Resistant Threats in the United States, 2013. 6 2
9/21/2017 The Basis of Antimicrobial Stewardship • Statement by Sir Alexander Fleming to the New York Times on June 26, 1945: • “…the microbes are educated to resist penicillin and a host of penicillin ‐ fast organisms is bred out…In such cases the thoughtless person playing with penicillin is morally responsible for the death of the man who finally succumbs to infection with the penicillin ‐ resistant organism. I hope this evil can be averted.” Fishman N. Infect Control Hosp Epidemiol . 2012; 33: 322–7. 7 Antibiotic Timeline 1972 – Vancomycin Introduced 1996 – Levofloxacin 1967 – Gentamicin Introduced 1943 ‐ PCN Enters Introduced Mass Production 1985 – Ceftazidime 1960 ‐ Methicillin Introduced Introduced 1940 ‐ PCN 2009 – PDR 1988 ‐ VRE 1979 – Gentamicin resistant S. aureus Enterobacteriaceae 1962 ‐ MRSA resistant Enterococcus 2002 ‐ VRSA 1965 – PCN 1987 – Ceftazidime resistant resistant S. Enterobacteriaceae pneumoniae 1996 – Levofloxacin PCN = Penicillin; MRSA = Methicillin Resistant Staphylococcus aureus ; VRSA = Vancomycin Resistant Staphylococcus aureus ; VRE = Vancomycin resistant Enterococcus; PDR = Pandrug ‐ resistant resistant S. pneumoniae CDC. Antibiotic Resistant Threats in the United States, 2013. 8 Colistin Resistance in the US • On May 31, 2016 the Centers for Disease Control and Prevention (CDC) issued a press release stating that the mcr ‐ 1 gene was identified for the first time in the US in E. coli • Codes for resistance to colistin, which is often the last line of therapy for multidrug ‐ resistant (MDR) Gram negative infections • The gene is encoded on a plasmid, meaning it can be transferred to other bacteria (including other species) CDC. Discovery of first mcr ‐ 1 gene in E. coli bacteria found in a human in United States. 9 3
9/21/2017 What percentage of antibiotic prescriptions are inappropriate? A. 5 ‐ 10% B. 10 ‐ 30% Que Questio ion 1 C. 20 ‐ 50% D. 40 ‐ 60% E. 50 ‐ 75% 10 What are the Primary Goals of an Antimicrobial Stewardship Program (ASP)? 1 2 3 4 Improve patient Reduce rates of Reduce rates of Reduce costs outcomes antimicrobial Clostridium resistance difficile infection (CDI) CDC. Core Elements of Hospital Antibiotic Stewardship Programs. 11 Barlam TF, Cosgrove SE, Abbo LM, et al. Clin Infect Dis . 2016; 62: 51 ‐ 77 Preauthorization • A strategy in which prescribers are required to obtain approval in order to prescribe certain antibiotics • Results in significant reduction in usage of restricted antibiotics • Reduces costs associated with restricted antibiotics • Decreased antimicrobial resistance • No adverse effects on patient outcomes CDC. Core Elements of Hospital Antibiotic Stewardship Programs. 12 Barlam TF, Cosgrove SE, Abbo LM, et al. Clin Infect Dis . May 2016; 62(10): e51 ‐ e77. 4
9/21/2017 Preauthorization Advantages • Reduces initiation of unnecessary/ inappropriate antimicrobials • Optimizes empiric choices and influences downstream use • Prompts review of clinical data/prior cultures at the time of initiation of therapy • Decreases antimicrobial costs, including those due to high ‐ cost agents • Provides mechanism for rapid response to antimicrobial shortages • Direct control over antimicrobial use CDC. Core Elements of Hospital Antibiotic Stewardship Programs. 13 Barlam TF, Cosgrove SE, Abbo LM, et al. Clin Infect Dis . May 2016; 62(10): e51 ‐ e77. Preauthorization Disadvantages Impacts use of restricted agents only • Addresses empiric use to a much greater degree than downstream use • Loss of prescriber autonomy • May delay therapy • Effectiveness depends on skill of approver • Real ‐ time resource intensive • Potential for manipulation of system (e.g., presenting request in a biased manner to gain • approval) May simply shift to other antibiotic agents and select for different antibiotic ‐ resistance • patterns CDC. Core Elements of Hospital Antibiotic Stewardship Programs. 14 Barlam TF, Cosgrove SE, Abbo LM, et al. Clin Infect Dis . May 2016; 62(10): e51 ‐ e77. Prospective Audit & Feedback (PAF) • A strategy in which prescribing of antimicrobials is monitored and assessed by a person or persons other than the prescribing team • The prescribing team is given education and advice on how to best tailor the antimicrobial regimen to the patient • PAF has been shown to improve antimicrobial use, reduce antimicrobial resistance, and reduce CDI rates • No adverse effects on patient outcomes CDC. Core Elements of Hospital Antibiotic Stewardship Programs. 15 Barlam TF, Cosgrove SE, Abbo LM, et al. Clin Infect Dis . May 2016; 62(10): e51 ‐ e77. 5
9/21/2017 Prospective Audit & Feedback (PAF) Advantages • Can increase visibility of antimicrobial stewardship program and build collegial relationships • More clinical data available for recommendations, enhancing uptake by prescribers • Greater flexibility in timing of recommendations • Can be done on less than daily basis if resources are limited • Provides educational benefit to clinicians • Prescriber autonomy maintained • Can address de ‐ escalation of antimicrobials and duration of therapy CDC. Core Elements of Hospital Antibiotic Stewardship Programs. 16 Barlam TF, Cosgrove SE, Abbo LM, et al. Clin Infect Dis . May 2016; 62(10): e51 ‐ e77. Prospective Audit & Feedback (PAF) Disadvantages • Compliance voluntary • Typically labor ‐ intensive • Success depends on delivery method of feedback to prescribers • Prescribers may be reluctant to change therapy if patient is doing well • Identification of interventions may require information technology support and/or purchase of computerized surveillance systems • May take longer to achieve reductions in targeted antimicrobial use CDC. Core Elements of Hospital Antibiotic Stewardship Programs. 17 Barlam TF, Cosgrove SE, Abbo LM, et al. Clin Infect Dis . May 2016; 62(10): e51 ‐ e77. Preauthorization vs. PAF • A Cochrane review found that preauthorization and PAF had similar effects on prescribing outcomes at 12 and 24 months • Preauthorization was superior to PAF for prescribing outcomes at 1 month and for CDI at 6 months • Mehta et al. found that when preauthorization was changed to PAF, overall antibiotic use increased • Preauthorization and PAF are not mutually exclusive • A combination of both strategies can be effective CDC. Core Elements of Hospital Antibiotic Stewardship Programs.; Barlam TF, Cosgrove SE, Abbo LM, et al. Clin Infect Dis . May 2016; 62(10): e51 ‐ e77. 18 Davey P, Brown E, Charani E, et al. Cochrane Database Syst Rev . 2013; 4:CD003543.; Mehta JM, Haynes K, Wileyto EP, et al. Infect Control Hosp Epidemiol . 2014; 35:1092–9. 6
9/21/2017 All of the following statements about preauthorization are TRUE EXCEPT : A. Reduces costs associated with restricted antibiotics B. Decreases antimicrobial resistance Que Questio ion 2 C. Reduces prescriber autonomy D. Adversely affects patient outcomes E. Optimizes empiric antibiotic choices 19 All of the following statements about prospective audit & feedback (PAF) are TRUE EXCEPT : A. Results may take longer than preauthorization B. Does not adversely affect patient outcomes Questio Que ion 3 C. May be less popular with prescribers compared to preauthorization D. Success may depend on the delivery method of feedback E. Reduces antimicrobial resistance 20 Preauthorization and prospective audit & feedback (PAF) are mutually exclusive. Que Questio ion 4 True False 21 7
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