Objectives List the potential benefits of antimicrobial - PDF document

Antimicrobial Stewardship in Large Hospital Systems: Programs and Experiences Brad Laible, Pharm.D., BCPS-AQ ID Professor, Department of Pharmacy Practice, SDSU COP Clinical Pharmacy Specialist Avera McKennan Hospital July 22 nd , 2015 Objectives • List the potential benefits of antimicrobial stewardship. • Describe commonly used antimicrobial stewardship approaches. • Discuss possible barriers to implementing a successful antimicrobial stewardship program. • Explain why some antimicrobial stewardship approaches are more successful than others. • Identify opportunities for antimicrobial stewardship initiatives. Dellit TH, et al. Clin Infect Dis 2007 1

http://www.cdc.gov/getsmart/ healthcare/pdfs/checklist.pdf 2

https://www.whitehouse.gov/the- press-office/2015/03/27/fact- sheet-obama-administration- releases-national-action-plan- combat-ant Antimicrobial Stewardship • Process of promoting: – Appropriate antimicrobial(s) – Optimal dose – Optimal duration – Minimize toxicity – Minimize selection of secondary infections ( Clostridium difficile ) – Minimize conditions for selection of resistant strains Fishman N. Am J Med 2006 Ohl CA. Clin Infect Dis 2011 3

Why Antimicrobial Stewardship? • Multiple studies indicating antimicrobials are considered unnecessary or inappropriate in >50% of cases • Minimal antimicrobial compounds in development for treatment of resistant bacteria – Particularly Gram-negative organisms Dellit TH, et al. Clin Infect Dis 2007 Why Antimicrobial Stewardship? • Limited data for accomplishing reduction of: – Extended-Spectrum Beta-lactamase (ESBL) Gram negatives – Clostridium difficile-associated diarrhea – Vancomycin resistant Enterococci (VRE) – Carbapenem-resistant Enterobacteriaceae (CRE) • Proven reduction in drug cost Fishman N. Am J Med 2006 Dellit TH, et al. Clin Infect D is 2007 Types of Antimicrobial Stewardship • “Front-end” – Formulary restriction – Prior approval – Education programs / antibiogram distribution – Guidelines and clinical pathways – Antimicrobial order forms / order sets – Dose optimization protocols / consult services (vancomycin, aminoglycosides) Dellit TH, et al. Clin Infect Dis 2007 4

Types of Antimicrobial Stewardship • “Back End” – Streamlining or De-escalation • Following culture results and patient response to therapy and narrowing therapy accordingly • Multiple strategies: – Comprehensive review – Agents with required review – IV to PO switch • Most institutions use a hybrid of both Dellit TH, et al. Clin Infect Dis 2007 Difficulties with Antimicrobial Stewardship • Physician acceptance • Must be a multidisciplinary approach – Most effective with Infectious Disease attending and Clinical Pharmacist as core members • May require significant resources – Personnel – Time Dellit TH, et al. Clin Infect Dis 2007 Avera McKennan Antimicrobial Stewardship Program (ASP) • Collaborative effort between: – Avera McKennan Pharmacy – SDSU College of Pharmacy Faculty/Students – Infectious Disease Specialists, PC • Goal: – Proper Antimicrobial Stewardship 5

Avera ASP: 2004 - 2010 • What did we provide? – Targeted, but continuous antimicrobial regimen review of one patient care floor – Unsolicited recommendations targeted at improving antimicrobial therapy – Antimicrobial restriction for certain antimicrobials (hospital-wide) Targeted Patient Population • Avera McKennan Hospital – 1 West / 1 West D pod • Medical/Surgical/Trauma • 55 beds Antimicrobial Report (Meditech) Reviewed by Pharmacist and PharmD Students Pharmacist and PharmD Students Meet With Infectious Disease Physician for AMT Rounds Antimicrobial Management Communication (AMC) Completed if Recommendations Made Changes Deemed Urgent: Changes NOT Deemed Urgent: Contact Physician Leave AMC in Progress Notes 6

Results Laible BR, et al. J Pharm Pract 2010 Results Results 7

What Happened? • Picked all of the “low hanging fruit”? • Utilized one method too much? • Couldn’t maintain the effort? • Lack of focus? • ASP chose go another direction… Focused Stewardship • Wong-Beringer, et al. 2009 • ASP with a focus on reducing fluoroquinolone overuse • 565 bed, acute care, teaching hospital • Used multiple methods of stewardship – Monitoring and reporting of antibiogram data – Audit and feedback – IV to PO conversion – Empiric guidelines – Prescriber education Results • 30% decrease in fluoroquinolone utilization as empiric therapy for P. aeruginosa infections • 10% improvement in susceptibility of P. aeruginosa to antipseudomonal agents (both ciprofloxacin and structurally unrelated agents) • 2-fold reduction in mortality associated with Pseudomonal infections • Stable level of fluoroquinolone-resistant E. coli (~20%) Wong-Beringer, et al. Pharmacother 2009 8

Renewed efforts: Avera ASP Fluoroquinolone Avoidance Project 2011 - Current • Avera Stewardship Workgroup • ASP program for entire health-system • Focus on reduction of fluoroquinolone overuse • Multiple approaches to the effort: – Provider education – Electronic Order Set Revisions • Started with Pneumonia – Decentralized pharmacists providing audit and feedback 9

Results so far… Avera ASP: Next steps • Electronic Order Set Revisions: – Sepsis – General Surgery – Urinary Tract Infection – Cellulitis – Meningitis • Stewardship diversification – Clinical pathways – Enhanced Audit and Feedback – Utilization of available technology ASP Challenges • Proving worth • Maintaining the effort / sustaining results • Hospital or System Harmony 10

ASP: My Recommendations • Don’t take on too much – Formulary management (restrictions if able) – Education and antibiogram distribution – Treatment pathways / order sets – Policies / protocols that empower staff to optimize antimicrobial use and meet CMS requirements • “Back-end” strategies later • Monitor impact of your efforts Questions? 11