Antimicrobial Stewardship: Response to a Global Crisis Carla - PowerPoint PPT Presentation

Antimicrobial Stewardship: Response to a Global Crisis Carla Walraven, PharmD, BCPS-AQ ID University of New Mexico Hospital Antimicrobial Stewardship Program

Pharmacist Objectives • Explain the implications of antimicrobial resistance • Prepare for the new regulatory standards for Antimicrobial Stewardship Programs (ASPs) • Outline strategies employed by ASPs to improve outcomes • Identify opportunities to apply Antimicrobial Stewardship concepts

Pharmacy Technician Objectives • Identify ways in which antibiotics are misused • Explain the implications of antimicrobial resistance • Recognize the core elements of Antimicrobial Stewardship Programs

Audience Poll • A 19 YOM is brought to your ED after an accident cleaning his homemade shotgun, resulting in a penetrating eye socket injury with a metal pipe. – How many would recommend antibiotics? – Which antibiotics would you use? (What pathogens are you concerned about?)

The Curious Case of Phineas Gage (July 9, 1823 – May 21, 1860) • In 1848, Phineas Gage was struck by a tamping iron while working on the railroad • He survived the accident, but was not the same afterwards • Died at the age of 36, after a series of seizures http://www.smithsonianmag.com/history/phineas-gage-neurosciences-most-famous-patient-11390067/?no-ist

Fast Forward to 2016… • 61 YOM newly diagnosed ESBL E. coli MIC AML Amikacin 16 Susceptible • Antibiotic exposure: Aztreonam > 16 Resistant – Cetriaxone, clindamycin x Ciprofloxacin > 2 Resistant 14 days (shin injury) Ceftriaxone > 32 Resistant – Vancomycin (cellulitis) Cefazolin > 16 Resistant – Augmentin and ciprofloxain (prophylaxis) Ertapenem > 1 Resistant • Febrile neutropenia 16 Gentamicin > 8 Resistant days after admission Meropenem 4 Resistant – Blood cultures grew an Ampicillin/sulbac > 16/8 Resistant Extended spectrum β- Piperacillin/tazo > 64/4 Resistant lactamase (ESBL) E. coli Sulfameth/trimeth > 2/38 Resistant

Going Back to a Pre-Antibiotic Era? • Antibiotic resistance has been called one of the world’s most pressing public health concerns • Antibiotic resistance is associated with increased lengths of hospital stay, increased costs, and increased mortality https://www.cdc.gov/drugresistance/about.html

“ 30-50% of antimicrobial use is either unnecessary or inappropriate .” Most Common Reasons for Unnecessary Therapy 35% N = 576 DOT % of Patients with Unnecessary 30% 25% 20% DOT 15% 10% 5% 0% Noninfectious Tx of Duration of tx Redundant Syndrome Colonization or Longer than Abx Coverage Contamination Necessary Reimann HA, D’Ambola J. JAMA. 1968;205(7):537. Hecker MT, et al. Arch Intern Med. 2003;163:972-78.

Antibiotic Misuse • Antibiotics are given when they are not needed • Antibiotics are continued longer than necessary • Antibiotics are given at the wrong dose • Broad spectrum antibiotics are used to treat highly susceptible bacteria • The wrong antibiotic is used to treat an infection http://www.cdc.gov/getsmart/healthcare/evidence.html

Antibiotic Prescribing Trends in US Hospitals, 2006 - 2012 2006-2012 Baggs J, et al. JAMA Intern Med. doi:10.1001/jamainternmed.2016.5651

Piperacillin/tazobactam – Resistant Pseudomonas aeruginosa http://gis.cdc.gov/grasp/PSA/MapView.html, Accessed Aug 2016.

National Action Plan for Combating Antibiotic-Resistant Bacteria • 5 Goals – Slow the emergence and spread of resistant bacteria • Includes the implementation of antimicrobial stewardship programs – Strengthen national surveillance efforts of resistant bacteria – Advance development and use of rapid diagnostic tests – Accelerate research and development of new antibiotics, therapeutics, and vaccines – Improve international collaborations regarding antimicrobial use and misuse https://www.whitehouse.gov/sites/default/files/docs/national_action_plan_for_combating_antibotic-resistant_bacteria.pdf, Accessed Aug 2016.

What is Antimicrobial Stewardship? Coordinated program that promotes the appropriate use of antimicrobials, improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multi-drug resistant organisms. Barlam TF, et al. Clin Infect Dis. 2016; e1-e27. http://www.apic.org/Professional-Practice/Practice-Resources/Antimicrobial-Stewardship

CDC’s Core Elements for ASPs  Obtain leadership commitment • Includes dedicating necessary human, financial and information technology resources  Appoint a single leader responsible for program outcomes  Appoint a single pharmacist leader responsible for working to improve antibiotic use  Obtain support from key stakeholder • Infection control and prevention • Information technology • Quality improvement • Clinicians http://www.ahaphysicianforum.org/resources/appropriate-use/antimicrobial/content%20files%20pdf/CDC%20checklist.pdf

CDC’s Core Elements for ASPs (cont.)  Implement policies and interventions to improve antibiotic use  Evaluate ongoing treatment need after an initial treatment period • E.g. “Antibiotic timeout” after 48 hours  Monitor antibiotic prescribing and resistance patterns  Regularly report information on antibiotic use and resistance to doctors, nurses, and relevant staff  Educate clinicians about resistance and optimal prescribing

CMS § 482.42(b): Antibiotic Stewardship Program Organization and Policies • Effective January 1, 2017 • Demonstrate coordination among all components of the hospital responsible for antibiotic use and factors that lead to antimicrobial resistance • Document the evidence-based use of antibiotics in all departments and services of the hospital • Demonstrate improvements, including sustained improvements in proper antibiotic use https://s3.amazonaws.com/public-inspection.federalregister.gov/2016-13925.pdf

TJC’s New Antimicrobial Stewardship Standard Effective January 1, 2017 Download available at: https://www.jointcommission.org /standards_information/prepublic ation_standards.aspx

Antimicrobial Stewardship Team Hospital Admin Infection Microbiology Control ASP Physician Pharmacist Infectious Informatics Diseases Pharmacy

ASP Interventions ASP Activities Impact of Interventions • Patient Centered Goal: Decrease or slow – Prospective audit and review antimicrobial resistance – Formulary management – Identify patients who may benefit from ID consult Global National • Institutional Institution – Antibiograms Patient – Clinical pathways – Dose optimization

ASP Core Strategies Core Strategies Advantages Disadvantages Prospective audit with direct May reduce inappropriate Difficulty identifying • • intervention and feedback antimicrobial use patients with inappropriate Educate to modify future therapy and communicating • prescribing with prescribers Allows prescribers to • maintain autonomy Formulary restriction and May result in immediate May increase staffing • • preauthorization requirements and substantial reduction in requirements antimicrobial use and costs May delay order • implementation with potential adverse patient outcomes May increase use of and • resistance to alternative antimicrobial agents Perceived loss of prescriber • autonomy Dellit et al. Clin Infect Dis. 2007;44:159-77. Drew et al. Pharmacotherapy. 2009;29:593-607.

ASP Supplemental Strategies Supplemental Elements Advantages Disadvantages Education May influence prescribing Marginally effective when • • behavior used without active intervention Evidence based guidelines and May improve antimicrobial Poor adherence • • clinical pathways use and practice variations Streamlining or de-escalation Reduces antimicrobial Prescriber reluctance to de- • • therapy exposure, selection of escalate when cultures are resistant pathogens, and negative and clinical health care costs improvement observed Dose optimization Tailors therapy to patient Nursing concerns regarding • • characteristics, pathogen, incompatibilities and and PK/PD of antimicrobial administration IV to PO conversion May decrease length of Difficulty identifying patients • • hospital stay and costs in whom conversion is May reduce complications appropriate • associated with IV access Dellit et al. Clin Infect Dis. 2007;44:159-77. Drew et al. Pharmacotherapy. 2009;29:593-607.

Implementing Antimicrobial Stewardship PATIENT CASE

Healthcare-Associated Pneumonia • 49 YOF with history of severe COPD is admitted from a skilled nursing facility for respiratory distress and acute disorientation (per family) – Increased cough with sputum production over the past 24h – No fevers or chills • Diagnosis: Acute hypoxic respiratory failure due to healthcare-associated pneumonia (HCAP)/aspiration with sepsis

HCAP Physical Exam Vitals & Labs • General: Obese female, • T 37.6˚C, HR 123, BP respiratory distress, 151/73, RR 21, O 2 91% alert/responsive • WBC 24.4 • ENT: no nasal discharge • Lactate 1.8 • Respiratory: Bilateral rhonchi, crackles in right upper & • No medication allergies middle lobes, intermittent expiratory wheeze Patient is started empirically on vancomycin and piperacillin/tazobactam