Presentation on theme: "Antimicrobial Stewardship: The Never Ending Journey"— Presentation transcript:
1 Antimicrobial Stewardship: The Never Ending Journey Joan Ivaska, BS, MPH, CICSr Director, Infection PreventionBanner Health SystemDecember 12, 2013
2 About Banner Health 24 Acute Care Hospitals Banner Health Network Banner Medical Group with >800 doctorsBanner Health Centers and ClinicsBehavioral HospitalOutpatient SurgeryMedical Education2012 inpt. admissions/year: 241,6462012 ED visits/year: 733,9762012 surgeries/year: 133,532
3 Defining clinical practice at Banner Health Care Management CouncilMake systemwide clinical decisionsMembers include CMOs, CNOs, team leadersCM Clinical Consensus GroupsDetermine clinical practices based on best available evidenceIdentify opportunities for improving clinical careDefine expected and recommended clinical practices for Banner Health based on best available evidence.Oversee how clinical practices will be performed and implementedDefine, Design, and Implementation phasesReviews, revises and approves clinical order sets
4 ObjectivesDiscuss the importance of an antimicrobial stewardship programReview the SHEA/IDSA/PIDS Antimicrobial Stewardship Policy Statement and recommendationsReview Banner Health’s approach to antimicrobial stewardship
5 Antibiotic Use, Costs, and Financial Outcomes Annually in United States30% hospital admissions due to infection 12 million people develop HAI 223,000 of these individuals die as a direct result of this infection 530-50% hospitalized pts receive ABX 1,2200‐300 million antibiotics are prescribed annuallyUp to 50% ABX orders are unnecessary or inappropriate 1-330% of hospital pharmacy budget is composed of antimicrobials 4> $1.1 billion spent annually on unnecessary antibiotic prescriptions for respiratory infections in adults 5$15 million to treat 188 cases of ABX resistant infections 5Attributable costs 4MRSA: $9,275 - $13,901VRE: $27,190 per episodeResistant Enterobacter: $29,3791 Gums JG et al. Pharmacotherapy 1999;19: Owens Jr RC et al. Pharmacotherapy 2004;24: Arnold FW et al. J Manag Care Pharm 2004;10: Dellit TH et al. Clin Infect Dis 2007;44:6 Centers for Disease Control and Prevention, Antibiotic Resistant Threats in the United States, 2013.
6 In 2002, out of 89 new drugs, no new antibiotics were approved 2 Decline in the Number of New Antibacterial Agents Approved in the USA,Percent Decline in Approved Antibiotics Compared With (n=16 new agents)-10%-20%-30%-40%-50%-60%-70%-80%-90%1410752In 2006, only anidulafungin and posaconazole were approved (anti-fungals). No new antibacterials were approved in 2006 (AAC, July 2007, for new approvals on 2006). Only 1 (doripenem) was approved in NO new antibiotics were approved in 2008 (Nat Rev Drug Discov 2009; 8:93-6.)NOTE: Telavancin was approved on 9/11/09, but with a boxed warning regarding fetal risk . The FDA will require that the company distribute a Medication Guide to patients who receive the drug. Ceftaroline was approved 10/31/ It is doubtful that any “new” antibiotics will be approved by the FDA before the end of 2012.In 2002, out of 89 new drugs, no new antibiotics were approved 2Numbers in arrow bars represents # of new antimicrobials approved by the FDA during the 5-year period listed1 Boucher H et al. Clin Infect Dis 2009;48:1-12 (up to 2007) Infectious Diseases Society of America. Bad Bugs, No Drugs. July Available at:
7 Publically Available Information on Antibiotic Resistance: “A National Call to Action” The National Healthcare Safety Network (NHSN) evolved from the CDC’s NNIS project. Now, NHSN tracks HAIs, establishes benchmarks, and equates bacterial resistance as a patient safety issue.The IHI (Institute of Healthcare Initiatives) has established bundles for the improvement of HAI prevention. IHI is well-known for its “5 million lives” campaignThe Joint Commission released 3 new initiatives to their safety goals which encompass antibiotic stewardship and infection control.The Consumers Union website validates how consumers are wary of HAIs, and the website contains frightening testimonials.IDSA and SHEA co-authored a joint statement on antibiotic stewardship. This document is required reading for understanding the concepts and challenges of stewardship, but provides few tools with which to use.Finally, Pennsylvania is now in their 4th year collecting performance measures of accredited hospitals in PA. The report is accessible and is used by consumers to compare hospitals.To address the lack of antimicrobial agents in the research and development pipeline, the Infectious Diseases Society of America (IDSA)and several other organizations recently launched the “10 x ’20 initiative,” a call to action to develop 10 new antimicrobial drugs by the year Federal legislation—the Strategies to Address Antimicrobial Resistance Act (H.R known as STAAR)—was introduced in May 2009 to encourage the development of new antimicrobial agents as well as strengthen federal antimicrobial resistance surveillance, prevention and control, and research efforts.All of these resources are publically available and provide a clear sense of urgency to develop and implement stewardship programs.
8 Factors That Lead to Inappropriate Use of Antibiotics InternalExternalLack of knowledge of infectious diseases, e.g., “more antibiotics are better”“Double coverage is better for killing”“Expanding” spectrum when consolidation is betterLack of knowledge about antibioticsWhat agents cover what pathogens- broader is easier; vancomycin as “broad spectrum”Lack of knowledge about dosing-, e.g., “low dose for longer is better”Lack of knowledge of antibiotic allergies and their implicationsLack of knowledge about when to give and stop antibioticsProphylaxis outside of surgical theaterLack of time to educate patients and prescribers about when antibiotics are not indicatedLack of microbiologic data (and acquisition of it)Fear of malpractice for not giving an antibioticMisperception that antibiotics have only benefit and no harmPharmaceutical detailing - new does not always equal better
9 CDC 12 Steps to Prevent Antimicrobial Resistance in Hospitalized Adults Prevent InfectionVaccinateGet the catheters outDiagnose and Treat Infection EffectivelyTarget the pathogenAccess the expertsUse Antimicrobials WiselyPractice antimicrobial controlUse local dataTreat infection, not contaminationTreat infection, not colonizationKnow when to say “no” to vancomycinStop treatment when infection is cured or unlikelyPrevent Transmission11. Isolate the pathogenBreak the chain of contagionThe CDC program is important because control of antibiotic resistance MUST be attacked on a broad base, not just changing one class to another.The CDC slide set has been available as a free and downloadable slide set for several years, perfectly suited for a Grand Rounds lecture, yet few clinicians have seen it.Link still works (4/14/09)In a joint study with the CDC, John Hopkins and Univ Louisville Univ Hospital, 87% of potential interventions fit into one of the CDC’s 12-steps, and following staff education, the rate of compliance with recommendations to improve antimicrobial use was 72% 1CDC slides available at:1 Cosgrove S, et al. Infect Control Hosp Epidemiol. 2007;28:641-6
10 Impact of Antibiotic Stewardship Programs Hospital SizeParticipation by CliniciansAntimicrobial Cost SavingsDrug Resistance & Infectious Diseases OutcomesID MDClin RXMicroData AnalystIP/IC174 bedsxAnnual cost reduction: $200,000-$250,000Reduced rate of nosocomial Clostridium difficile and MDR-Enterobacteriaceae250 bedsCost-savings during 18 month study: $913,236Decreased resistance rates650 bedsNet savings for 1 year: $189,318Reduced rate of VRE colonization and bloodstream infections120 beds19% decrease ABX costs/pt; annual cost reduction: $177,000Not reportedMcQuillen D, et al. Clin Infect Dis.2008;47:
11 SHEA / IDSA / PIDS Policy Statement, 2012 Antimicrobial Stewardship Programs should be required through regulatory mechanismsAntimicrobial Stewardship should be monitored in ambulatory healthcare settingsEducation about antimicrobial resistance and antimicrobial stewardship must be accomplishedAntimicrobial use data should be collected and readily available for both inpatient and outpatient settingsResearch on antimicrobial stewardship is needed
12 IDSA Antibiotic Stewardship Guidelines Dellit TH, et al IDSA Antibiotic Stewardship Guidelines Dellit TH, et al. Clin Infect Dis. 2007;44:159-77Definition: Judicious use of antimicrobials in order to improve patients outcomes, control resistance and decrease healthcare expenseAchieved through:CORE STRATEGIESFormulary Pre-authorization & restrictionProspective audit with feedbackEducationStreamliningInformation TechnologyIV to PODose OptimizationGuidelinesClinical pathwaysOrder Sets
13 The Banner ANTIMICROBIAL STEWARDSHIP Plan– ADULT & PEDIATRIC Six Components:Formulary RestrictionTreatment guidelines/clinical pathwaysComputer surveillance and clinical decision supportEducationAuditing of Antimicrobial useA centralized system team for antimicrobial stewardship oversight
14 Purpose of Antimicrobial Stewardship Guide antimicrobial therapy usage to minimize toxicity, decrease emergence of resistance and selection of pathogenic organisms and improve / optimize patient care.
15 Clinical ProposalOverview: All inpatients will be treated with the appropriate antimicrobial agent(s) to optimize clinical outcomes while minimizing unintended consequences of antimicrobial use.Rationale:the use of antimicrobial medications can be associated with unintended consequences including: drug toxicity, super infection with Clostridium difficile, and emergence of resistant organisms.inappropriate use of antimicrobials remains a common occurrence in health care facilities contributing to increased costsantimicrobial resistance results in increased morbidity, mortality and health care costsEffective antimicrobial stewardship programs can improve patient care by optimizing the appropriate use of antimicrobials, resulting in improved patient outcomes and decreased costs.
16 Formulary Restrictions Antimicrobials may by restricted based on therapeutic efficacy, toxicity, and to minimize antimicrobial resistance and cost.Antimicrobial therapeutic substitutione.g., ceftaz to cefepime; caspo to micafungin; ambisome to abelcet, 1st and 2nd generation cephalosporinsDevelop Discern alerts to guide appropriate use of high-cost/broad spectrum agentsUse caresets to guide appropriate use of antimicrobial medications (e.g. sepsis)
20 Treatment Guidelines/ Clinical Pathways Treatment guidelines and clinical pathways will be developed incorporating evidence-based practice and local microbiology and resistance patterns.CCG Clinical Practices/Initiatives such as CAP, SepsisDe-escalation of empirical antimicrobial therapy based on culture results so as to eliminate redundant therapy and targeting the causative pathogen.Clinical Decision Support Discern AlertsDose optimization based on individual patient characteristics, causative organism, site of infection and drug characteristics.Pharmacy Renal Dosing ProtocolParenteral to oral conversion when the patients condition allows.Pharmacy IV to PO Conversion Protocol
21 Computer Surveillance and Clinical Decision Support Computer-based surveillance will provide clinical decision support to optimize clinical outcomes while minimizing unintended consequences of antimicrobial use.Prescriber Discern alerts for restricted antimicrobials to provide recommendations and record usage of selected antimicrobials.Pharmacy Discern alerts to identify potentially inappropriate/suboptimal antimicrobial therapy based on microbiology results and/or renal function
22 EducationEducation is an essential element for influencing prescribing behaviors and will be partnered with active interventions for greatest effectiveness (on-going education).Antimicrobial Stewardship SharePoint site will provide information related to Antimicrobial Stewardship at Banner.
23 Auditing Antimicrobial Use Retrospective audits of clinical decision support antimicrobial alerts at both a system and facility levelAdditional prospective or retrospective audits dependent on individual facility capabilitiesAudits to be performed by appropriate clinical personnel, including infectious disease physician, clinical pharmacist, infectious disease practitioner or other personnel as determined by facility capabilitiesMetrics measured may include usage patterns, patient outcomes, resistance trendsPrescribers who repeatedly utilize selected antimicrobials inappropriately will require intervention and feedback.
24 A centralized system team for Antimicrobial Stewardship Oversight Oversight Team to review the effectiveness of facilities and system implementation of the Banner Antimicrobial Stewardship Plan and to determine opportunities for improvement.
27 Partnering Opportunities Pharmacy-Microbiology & LaboratoryPharmacy-NursingPharmacy-Infection PreventionPharmacy-Medical StaffRapid testing and notification; MRSA v. MSSA BSIIV-to-PO transition therapiesReview CDI and MDRO cases for antibiotic useCPOE educational screensProcalcitonin resultsIdentification of “true” allergyNPSG 7.0’s for MDROAntibiotic plans in chartBlood culture contaminationEducation and support for prolonged infusionsHAIs treated optimallyEvidence-based treatment guidelinesAntibiogram development & educationRapid initiation of empiric antibioticsMaintenance of sterile injectablesTherapeutic interchangeEmpiric antibiotic prescribing guidelinesReminders to physicians: “did he/she see the C&S report?”Cleaning of equipment and rooms known to facilitate transmission of pathogensRestricted or non-formulary antibioticsSelective reporting rules on ASTSCIP guidelines; time to antibiotic administrationDifferentiate colonization from infectionOptimize clinical and economic outcomesCollaboration is essential, and this slide addresses.
28 Expected OutcomesAntimicrobial Stewardship to become part of daily clinical practice for all healthcare professionalsFull compliance with restricted uses for select antimicrobialsPharmacy evaluation, provider follow-up when indicated and complete documentation of pharmacy antimicrobial Discern alerts.Completion of Pharmacy Audits and Provider follow-upCost savings associated with antimicrobial use
30 Developing an Antibiotic Stewardship Program: The Core Team and Supporting Stakeholders Support TeamInfection ControlQuality Assurance/ Patient SafetyInformation TechnologyHospital EpidemiologistMicrobiologyCore TeamInfectious Disease PhysicianClinical Pharmacist with ID TrainingCollaborative TeamMed Executive & Pharmacy and Therapeutics CommitteesHospital Administration & Pharmacy DirectorAZ Partnership for ASP, 2012
31 How to Get Started Essential components for successful ASP Support and collaboration of hospital administration, medical staff leadership, and local providersFunction as a quality assurance and patient safety initiativeCoordinate activities between key stakeholders (e.g. Infectious Diseases, Pharmacy, Infection Control and Microbiology)Collaborate and obtain adequate authority to perform activitiesIdentify expected outcomes for the programDellit TH, et al. Clin Infect Dis. 2007;44:159-77
32 Twelve Steps to Implementing an ASP 1Assess motivations for an ASP7Define how progress is to be measured; what constitutes success?2Identify physician champion; form core group (physician-pharmacy)8Establish an implementation plan; identify phases3Gain administration support (includes P&T, Med Exec, Departments); business model and physician compensation plan developed9Identify resources (education of pharmacists, tools, training, medical meetings, networking, society membership, software)4Identify which of the defined problems/issues will be addressed by the ASP10Establish frequency of monitoring and documentation; daily activities and hierarchy of notifications5Assess barriers to success (level of education, work flow)11Establish mechanism and schedule for reporting of results (to whom?; with what?)6Identify Team members, roles, responsibilities, and accountabilities; meeting frequency12Market the program (internal and external; insurers/contract groups)
33 Accounting for the Non-Academic Medical Center Comprehensive program led by ID physician or physician champion, plus clinical pharmacistIndividual interventions based on goals of institution, with assistance from interested individualsFormulary management strategies:Simple audit (review of orders) of specific drugs - 10 patientsPharmacy order entry system (unsophisticated)Develop evidenced-based guidelines for 3-4 agents (see IDSA guidelines as a start)Educate medical staff (2-minute “elevator speech”)All pharmacists can apply guidelines and approve drugsPost-prescription review on days 2-3 with physician championIV-to-PO conversion is a good demonstration projectSCIP guidelines and other performance outcomes and measures
34 Barriers…Perceived and Real: Infectious Diseases Pharmacist DilemmaThe number of “ID-trained” clinical pharmacists doesn’t match the demand, nor do the number of training programsRequiring completion of a post-graduate ID training program to administer stewardship would be an impediment at presentPossible solutions:Financial and administrative support for in-house and external programs and trainingPrograms developed by professional organizations“Tool kits” to direct baseline activities and enhance existing onesBest practice sharing (e.g. round tables, web-based)Partner with other clinical pharmacy specialist colleagues and/or staff pharmacist to accomplish any or all componentsErnst EJ et al. Pharmacother 2009;29:
35 Computer Decision Support Systems (CDSS): Programmable Dashboards Programming current computer systems may assist in targeting antibiotic prescribing activitiesCommercial systems (~8) are available for purchase at an appreciable costPotential IdentifiersCore measure assessments (CAP)Pathogen-drug mismatchCreatinine clearance and targeted antibioticsPatients on ≥ 3 antibioticsIdentify antibiotics as IV-to-PO candidatesRecent positive culturesRestricted antibiotic listsAntibiotic therapy ≥ 7 daysVancomycin ≥ 3 days with + culture for a Gram-positive pathogenVancomycin therapy for unlikely pathogenDuplicative therapyDisease-drug mismatch (Zyvox-UTI)New slide for CDSS part; insert with slides #62-#66?
36 Keys to Success One size does not fit all Perform a baseline assessment of assets, deficits; gather pilot dataAddress any deficits that will impede the basic program and fix firstPre-determine barriers: differentiate the real from the misunderstoodPro-actively address the valid obstaclesPrioritize available resources as well as additional resources neededChoose reasonable, sequential initiatives that are practical and beneficial to the institution and will lead to a logical progression of next stepsBring in the specialists but realize everyone has a stake in the program…involve them, encourage them, educate them, report back to them (good and bad)Cost-reduction of the antimicrobial budget is not a primary justification for antimicrobial stewardship, but cost-savings will be realized from AST activitiesCreate a campaign towards antibiotic stewardship
37 Antibiotic Stewardship: Lessons Learned “Several strategies, including prescriber education, formulary restriction, prior approval, streamlining, antibiotic cycling, and computer-assisted programs have been proposed to improve antibiotic use. Although rigorous clinical data in support of these strategies are lacking, the most effective means of improving antimicrobial stewardship will most likely involve a comprehensive program that incorporates multiple strategies and collaboration among various specialties within a given healthcare institution.” 1Education/guideline strategiesPatient EvaluationChoice of antimicrobialto prescribePrescription orderingDispensing of antimicrobialAntibiotic cycling strategiesFormulary/restriction strategiesComputer-assisted strategiesReview and feedback strategiesFigure adapted from: MacDougall C et al.. Clin Microbiol Rev. 2005;18(4):1 Fishman N. Am J Infect Control. 2006;34:S55-63.