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Campaign to Prevent Antimicrobial Resistance Centers for Disease Control and Prevention National Center for Infectious Diseases Division of Healthcare.

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Presentation on theme: "Campaign to Prevent Antimicrobial Resistance Centers for Disease Control and Prevention National Center for Infectious Diseases Division of Healthcare."— Presentation transcript:

1 Campaign to Prevent Antimicrobial Resistance Centers for Disease Control and Prevention National Center for Infectious Diseases Division of Healthcare Quality Promotion  Link to: Campaign to Prevent Antimicrobial Resistance OnlineCampaign to Prevent Antimicrobial Resistance Online  Link to: Federal Action Plan to Combat Antimicrobial ResistanceFederal Action Plan to Combat Antimicrobial Resistance Clinicians hold the solution!

2 12 Steps to Prevent Antimicrobial Resistance: Hospitalized Adults Campaign to Prevent Antimicrobial Resistance in Healthcare Settings 12 Break the chain 11 Isolate the pathogen 10 Stop treatment when cured 9 Know when to say “no” to vanco 8 Treat infection, not colonization 7 Treat infection, not contamination 6 Use local data 5 Practice antimicrobial control 4 Access the experts 3 Target the pathogen 2 Get the catheters out 1 Vaccinate Prevent Transmission Use Antimicrobials Wisely Diagnose & Treat Effectively Prevent Infections

3 Fact: Programs to improve antimicrobial use are effective. Use Antimicrobials Wisely Step 5: Practice antimicrobial control 12 Steps to Prevent Antimicrobial Resistance: Hospitalized Adults

4 Methods to Improve Antimicrobial Use  Passive prescriber education  Standardized antimicrobial order forms  Formulary restrictions  Prior approval to start/continue  Pharmacy substitution or switch  Multidisciplinary drug utilization evaluation (DUE)  Interactive prescriber education 12 Steps to Prevent Antimicrobial Resistance: Hospitalized Adults Step 5: Practice antimicrobial control  Link to: SHEA / IDSA: Guidelines for the Prevention of Antimicrobial ResistanceSHEA / IDSA: Guidelines for the Prevention of Antimicrobial Resistance in Hospitals Effective and Increasingly Used Resource intensive up front

5 Multi-prong approaches Abx management teams Computerized systems

6 Which ASP component is most helpful?

7 Hospitalwide Program ßBantar, CID, 2003 ßASP ßID MD ßClin Microbiologist ßLab Microbiologist ß2 Pharmacists ßIM MD ßNo formulary restrictions

8 Hospitalwide Program ß4 step intervention phased in every 6 mos ßOptional Antibiotic order forms ßMandatory Abx forms with feedback ßReview of every Abx order and education ßModification by AMT if necessary ßGoal ßDecrease 3rd gen Ceph ßIncrease BL/Blase inhibitor

9 Hospitalwide Program

10

11 IamsCarb Iams Vanco Icfp

12 Hospitalwide Program ßCost savings occur most with mandatory ordering forms

13 Hospitalwide Program ßCost savings occur most with mandatory ordering forms BUT ßImpact in resistance did not occur until full program in place

14 Computerized Systems

15 Computerized Program ßPestotnik, Annals IM, 1996 ßEvans, NEJM, 1998 ßLDS hospital ßComputerized guidelines ßDevelopment ßIntergrated information ßHistory ßLabs ßCultures ßGuidelines ßAbx choices ßAbx dosing ßAbx duration

16 Outcomes

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18 76 % few adverse drug events

19 Longterm followup

20 Carling, 2003 ßBoston community hospital ßASP program ßOutcomes ßCosts ßRates of C. difficile/ R GNR infection ßAntibiogram vs. NNIS data

21 Carling, 2003

22 VRE

23 Carling, 2003 ßImpact of ASP long-lasting ßCosts ßNosocomial pathogens ßAbility to handle new resistant pathogens

24 Local example of impact

25 Local

26 HCSD Beginnings ßData ßPharmacy and Utilization from ILH and HCSD systems offices ßMDRO from ILH and HCSD Quality Compass ßILH team ßXavier PharmD faculty (Brakta, Johnson, Bryant, Al-Dahir) ßILH Pharmacy (Cardwell, Terry) ßILH IC (Friloux, Bergeron) ßILH Microbiology Lab (Wall) ßHCSD Pharmacy (Jackson) ßID/IC Faculty (Hull, Maffei, Figueroa) ßCCM Faculty (deBoisBlanc) ßHCSD ASP committee ßID chair (Brown) ßSimilar personnel from other HCSD facilities

27 ILH ASP team

28 Beginnings ßEvaluation of drug costs and utilization ßEvaluation of length of stay ßReview and evaluation of order sets and protocols ßEvaluation of distribution of leading diagnoses ßReview of antibiograms and MDRO rates

29 Antibiotic utilization

30 Abx doses 5/17/10 -11/17/10

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32

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34 Length of Stay

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36 Antibiotic Use by HCSD hospital

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40 MDRO rates

41 ILH

42 Next Steps for ILH ßImplementation of cellulitis protocol ßDaily review of broad spectrum Abx with de- escalation recommendations ßProlonged beta-lactam dosing ßCOPD/asthma protocol ßLimited microbiology Abx reporting ßPharmacokinetic service for vancomycin and aminoglycosides

43 Outcomes tracked ßBroad spectrum Abx use ßLength of stay for infectious disease diagnoses ßMDRO rates

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45 Top 65 ICD9 codes by HCSD hospital

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47 Jump!

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49

50 3rd gen Ceph Restriction ßEmpey, 2002 ß1999 formulary change ßCefepime for 3rd gen C ßEncourage BL/Blase combo ßVanco 72 hr stop ßRetrospective ßAntibiogram 6 mos before and after change

51 3rd gen Ceph Restriction ßEmpey, 2002 ß1999 formulary change ßCefepime for 3rd gen C ßEncourage BL/Blase combo ßVanco 72 hr stop ßRetrospective ßAntibiogram 6 mos before and after change

52 Abx susceptibilities

53 Your results may vary! ßNo decrease in monthly total abx costs ßShift to cefepime and carbepenem ßBut decreased cephalosporin costs ($38K to $30K) ßNeed to control carbepenem and cefepime use ßAvoid carbepenem-R Pseudomonas/ Acinetobacter ßAdvocate for narrowness of spectrum

54 3rd gen Ceph Restriction ßDu, CCM, 2003 ßProspective study ßPeking, China ßICU pts ßBefore and after 3rd gen Ceph restriction ( ) ßExcept Surg prophylaxis ßSwitched to cefepime or carbepenem ßOutcomes of ICU infx ß80 in 2000 (before) ß83 in 2001 (after)

55 3rd gen Ceph Restriction ßDu, CCM, 2003 ßProspective study ßPeking, China ßICU pts ßBefore and after 3rd gen Ceph restriction ( ) ßExcept Surg prophylaxis ßSwitched to cefepime or carbepenem ßOutcomes of ICU infx ß80 in 2000 (before) ß83 in 2001 (after)

56 Total infection isolates

57 Abx resistance Total isolates

58 Outcomes OutcomePhase I (n 80)Phase II (n 83) ICU stay, days29.3 ± ± 14.8 Infx-related death29 (36.3)16 (19.3) Pseudomonas19/47 (40.4)6/42 (14.3) Acinetobacter16/39 (41.0)11/41 (26.8) Stenotrophomonas8/20 (40.0)4/20 (20.0) Ecoli and Kleb4/18 (22.2)2/28 (7.1) Enterobacter9/21 (42.9)4/9 (44.4) Cefepime S org5/18 (27.8)2/38 (5.3) Cefepime R org24/62 (38.7)14/45 (31.1)

59 Outcomes OutcomePhase I (n 80)Phase II (n 83) ICU stay, days29.3 ± ± 14.8 Infx-related death29 (36.3)16 (19.3) Pseudomonas19/47 (40.4)6/42 (14.3) Acinetobacter16/39 (41.0)11/41 (26.8) Stenotrophomonas8/20 (40.0)4/20 (20.0) Ecoli and Kleb4/18 (22.2)2/28 (7.1) Enterobacter9/21 (42.9)4/9 (44.4) Cefepime S org5/18 (27.8)2/38 (5.3) Cefepime R org24/62 (38.7)14/45 (31.1)

60 Outcomes OutcomePhase I (n 80)Phase II (n 83) ICU stay, days29.3 ± ± 14.8 Infx-related death29 (36.3)16 (19.3) Pseudomonas19/47 (40.4)6/42 (14.3) Acinetobacter16/39 (41.0)11/41 (26.8) Stenotrophomonas8/20 (40.0)4/20 (20.0) Ecoli and Kleb4/18 (22.2)2/28 (7.1) Enterobacter9/21 (42.9)4/9 (44.4) Cefepime S org5/18 (27.8)2/38 (5.3) Cefepime R org24/62 (38.7)14/45 (31.1)

61 Outcomes OutcomePhase I (n 80)Phase II (n 83) Site-assoc mortality Lower respiratory tract 28/61 (45.9)15/58 (25.9) Bloodstream5/10 (50.0)1/9 (11.1) Abdomen2/20 (10.0)1/27 (3.7) Central venous catheter 3/5 (60.0)1/7 (14.3) Surgical wound2/8 (25.0)2/28 (7.1) Urinary tract2/7 (28.6)1/3 (33.3)

62 Logistic Regression Risk FactorOdds Ratio95% CI Infection with E coli or Kleb Restriction of 3rd gen C Immuno- compromised Pneumonia CVVH

63 Formulary restrictions ß3rd gen Cephalosporin restriction ßDecrease resistance ßDecrease costs ? ßDecrease mortality in ICUs ? ßFuture questions ßRestriction of all cephalosporins ßRestriction of carbepenems ßRestriction of quinolones ? ßRestriction of anti-anaerobic Abx

64 Antibiotic management teams ßComposed of: ßClinical pharmacist ßID specialist ßMicrobiology lab representative ßInfection control representative

65 Antibiotic stewardship programs ßComposed of: ßClinical pharmacist ßID specialist ßMicrobiology lab representative ßInfection control representative ßDuties ßEducation ßPractice guidelines for common diseases ßFormulary selections/restrictions ßActive surveillence and intervention ßDirect feedback

66 Results ßGross, CID 2001 ßMulti-step program ßLimited available formulary with many restrictions ßTreatment guidelines ßTeam to approve restricted Abx ßComparison of Team vs. ID fellow approvals on patients without ID consult (180 calls) in Nov 1993 ßOutcomes and Costs ßAppropriateness ßCure ßFailure ßCosts

67 Results ßGross, CID 2001 ßMulti-step program ßLimited available formulary with many restrictions ßTreatment guidelines ßTeam to approve restricted Abx ßComparison of Team vs. ID fellow approvals on patients without ID consult (180 calls) in Nov 1993 ßOutcomes and Costs ßAppropriateness ßCure ßFailure ßCosts

68 Multivariate analysis for appropriateness VariableOR95%CI ASP vs ID fellows Surg vs. Medical team Other vs. Medical team Oncological comorbidity Neurological comorbidity

69 Multivariate analysis for treatment failure VariableOR95%CI ASP vs ID fellows GI comorbid ICU stay Sepsis

70 Factors making recommendations inappropriate FactorASPID Fellow OR95%CI Cost Too broad Too narrow Inapprop spectrum Not indicated Route inapprop02 Dose inapprop02

71 Factors making recommendations inappropriate FactorASPID Fellow OR95%CI Cost Too broad Too narrow Inapprop spectrum Not indicated Route inapprop02 Dose inapprop02

72 Factors making recommendations inappropriate FactorASPID Fellow OR95%CI Cost Too broad Too narrow Inappropriate spectrum Not indicated Route inapprop02 Dose inapprop02

73 Cost outcomes Mean cost per group OutcomeASPID Fellow Total cost after approval call $6468$7864 Cost attributable to infection $3510$4205 Cost of antimicrobials$79$122

74 Conclusions ASP still has benefits Even with a restricted formulary based ID approval

75 Methods to Improve Antimicrobial Use  Passive prescriber education 12 Steps to Prevent Antimicrobial Resistance: Hospitalized Adults Step 5: Practice antimicrobial control  Link to: SHEA / IDSA: Guidelines for the Prevention of Antimicrobial ResistanceSHEA / IDSA: Guidelines for the Prevention of Antimicrobial Resistance in Hospitals

76 Methods to Improve Antimicrobial Use  Passive prescriber education 12 Steps to Prevent Antimicrobial Resistance: Hospitalized Adults Step 5: Practice antimicrobial control  Link to: SHEA / IDSA: Guidelines for the Prevention of Antimicrobial ResistanceSHEA / IDSA: Guidelines for the Prevention of Antimicrobial Resistance in Hospitals

77 Methods to Improve Antimicrobial Use  Passive prescriber education  Standardized antimicrobial order forms  Formulary restrictions  Prior approval to start/continue 12 Steps to Prevent Antimicrobial Resistance: Hospitalized Adults Step 5: Practice antimicrobial control  Link to: SHEA / IDSA: Guidelines for the Prevention of Antimicrobial ResistanceSHEA / IDSA: Guidelines for the Prevention of Antimicrobial Resistance in Hospitals

78 Methods to Improve Antimicrobial Use  Passive prescriber education  Standardized antimicrobial order forms  Formulary restrictions  Prior approval to start/continue 12 Steps to Prevent Antimicrobial Resistance: Hospitalized Adults Step 5: Practice antimicrobial control  Link to: SHEA / IDSA: Guidelines for the Prevention of Antimicrobial ResistanceSHEA / IDSA: Guidelines for the Prevention of Antimicrobial Resistance in Hospitals Successful, but only if resources to ensure oversight

79 Methods to Improve Antimicrobial Use  Passive prescriber education  Standardized antimicrobial order forms  Formulary restrictions  Prior approval to start/continue 12 Steps to Prevent Antimicrobial Resistance: Hospitalized Adults Step 5: Practice antimicrobial control  Link to: SHEA / IDSA: Guidelines for the Prevention of Antimicrobial ResistanceSHEA / IDSA: Guidelines for the Prevention of Antimicrobial Resistance in Hospitals Successful, but only if resources to ensure oversight 40% of hospitals with restricted formulary 60% of hospitals with automatic stops

80 Just say no! ßAssociated with: ßMDR GNR ßMRSA ßVRE ßC. difficile 3rd gen Cephalosporins

81 Just say no! ßAssociated with: ßMDR GNR ßQuinolone R GNR ßQuinolone R Spn ßMRSA ßC. difficile Quinolones

82 Just say no! ßAssociated with: ßVRE ßConcern for VISA ßConcern for VRSA Vancomycin

83 Methods to Improve Antimicrobial Use  Passive prescriber education  Standardized antimicrobial order forms  Formulary restrictions  Prior approval to start/continue  Pharmacy substitution or switch 12 Steps to Prevent Antimicrobial Resistance: Hospitalized Adults Step 5: Practice antimicrobial control  Link to: SHEA / IDSA: Guidelines for the Prevention of Antimicrobial ResistanceSHEA / IDSA: Guidelines for the Prevention of Antimicrobial Resistance in Hospitals

84 Methods to Improve Antimicrobial Use  Passive prescriber education  Standardized antimicrobial order forms  Formulary restrictions  Prior approval to start/continue  Pharmacy substitution or switch 12 Steps to Prevent Antimicrobial Resistance: Hospitalized Adults Step 5: Practice antimicrobial control  Link to: SHEA / IDSA: Guidelines for the Prevention of Antimicrobial ResistanceSHEA / IDSA: Guidelines for the Prevention of Antimicrobial Resistance in Hospitals Can reduce costs But not always accepted by MDs

85 Methods to Improve Antimicrobial Use  Passive prescriber education  Standardized antimicrobial order forms  Formulary restrictions  Prior approval to start/continue  Pharmacy substitution or switch  Multidisciplinary drug utilization evaluation (DUE)  Interactive prescriber education 12 Steps to Prevent Antimicrobial Resistance: Hospitalized Adults Step 5: Practice antimicrobial control  Link to: SHEA / IDSA: Guidelines for the Prevention of Antimicrobial ResistanceSHEA / IDSA: Guidelines for the Prevention of Antimicrobial Resistance in Hospitals

86 Hospitalwide Program ß4 step intervention phased in every 6 mos ßOptional Antibiotic order forms ßMandatory Abx forms with feedback ßReview of every Abx order and education ßModification by AMT if necessary ßGoal ßDecrease 3rd gen Ceph ßIncrease BL/Blase inhibitor

87 Hospitalwide Program ßRatios of preferred abx to 3rd gen Ceph ßIams = aminopen/sulbactam to 3rd gen Ceph ßIcfp = cefepime to 3rd gen Ceph

88 Methods to Improve Antimicrobial Use  Passive prescriber education  Standardized antimicrobial order forms  Formulary restrictions  Prior approval to start/continue  Pharmacy substitution or switch  Multidisciplinary drug utilization evaluation (DUE)  Interactive prescriber education  Provider/unit performance feedback  Computerized decision support/on-line ordering 12 Steps to Prevent Antimicrobial Resistance: Hospitalized Adults Step 5: Practice antimicrobial control  Link to: SHEA / IDSA: Guidelines for the Prevention of Antimicrobial ResistanceSHEA / IDSA: Guidelines for the Prevention of Antimicrobial Resistance in Hospitals

89 Computerized Antimicrobial Decision Support  Local clinician-derived consensus guidelines embedded in computer- assisted decision support programs  62,759 patients receiving antimicrobials over 7 years Medicare case-mix index Hospital mortality3.65%2.65% Antimicrobial cost per treated patient $122.66$51.90 Properly timed preoperative antimicrobial 40% 99.1%  Stable antimicrobial resistance  Adverse drug events decreased by 30% Source: Pestotnik SL, et al: Ann Intern Med 1996;124: Steps to Prevent Antimicrobial Resistance: Hospitalized Adults Step 5: Practice antimicrobial control

90 Computerized Program ßEvans, NEJM, 1998 ßICU patients ßPre-intervention ßOpen formulary ßBaseline ßIntervention ßOpen formulary ßComputer program ßCould reject ßHad to explain deviation from recommendations ßOutcomes ßCost ßQuality of care

91 Computerized Systems ßAdvantages ßAll information available immediately (save time) ßShorter patient LOS (save money) ßPut guidelines into place (save patients; save antibiotics) ßDisadvantages ßCostly, complicated system to maintain with intergration of multiple sources of information ßRemoves autonomy ?

92

93 Pharm

94 Micro Pharm

95 Micro ID/ICPharm

96 Micro ID/ICPharm MD


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