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Campaign to Prevent Antimicrobial Resistance

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1 Campaign to Prevent Antimicrobial Resistance
Centers for Disease Control and Prevention National Center for Infectious Diseases Division of Healthcare Quality Promotion The Centers for Disease Control and Prevention (CDC), the National Institutes of Health (NIH), and the Food and Drug Administration (FDA) led a task force of 10 agencies to develop a comprehensive plan to address the emerging threat of antimicrobial resistance. One of the top priority items in the plan is “ In collaboration with many partners, develop and facilitate the implementation of educational and behavioral interventions that will assist clinicians in appropriate antimicrobial prescribing.” In conjunction with the CDC Foundation, corporate partners, professional societies, healthcare organizations, public health agencies, and expert consultants, CDC’s Campaign to Prevent Antimicrobial Resistance is a nationwide effort to address this priority. Clinicians hold the solution! Link to: Campaign to Prevent Antimicrobial Resistance Online Link to: Federal Action Plan to Combat Antimicrobial Resistance

2 12 Steps to Prevent Antimicrobial Resistance: Hospitalized Adults
Campaign to Prevent Antimicrobial Resistance in Healthcare Settings 12 Steps to Prevent Antimicrobial Resistance: Hospitalized Adults 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 The “12 Steps to Prevent Antimicrobial Resistance: Hospitalized Adults” intervention program is the first “12 Steps” to be launched because hospital patients are at especially high risk for serious antimicrobial-resistant infections. Each year nearly 2 million patients in the United States get an infection in a hospital. Of those patients, about 90,000 die as a result of their infection. More than 70% of the bacteria that cause hospital-acquired infections are resistant to at least one of the drugs most commonly used to treat them. Persons infected with antimicrobial-resistant organisms are more likely to have longer hospital stays and require treatment with second-or third-choice drugs that may be less effective, more toxic, and/or more expensive.

3 antimicrobial control
12 Steps to Prevent Antimicrobial Resistance: Hospitalized Adults Use Antimicrobials Wisely Step 5: Practice antimicrobial control The importance of wise use of antimicrobials has been emphasized for many years. Many hospital-based programs to improve antimicrobial utilization have been implemented. Fact: Programs to improve antimicrobial use are effective.

4 Methods to Improve Antimicrobial Use
12 Steps to Prevent Antimicrobial Resistance: Hospitalized Adults Step 5: Practice antimicrobial control 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 Passive education of healthcare personnel is probably the least effective strategy for improving antimicrobial use, but does have some impact. Strategies designed to limit use, including antimicrobial order forms, formulary restrictions, and approval systems, can be successful, but only if resources are applied to ensure oversight and response. Automatic pharmacy substitution of one similar drug for another or from one route of administration to another (e.g. IV to oral) can be highly successful in reducing costs, but is not always acceptable to clinicians. Multidisciplinary drug utilization evaluation is an approach favored in institutions that have successfully engaged the appropriate professionals in the process, but does require up-front personnel resources to have maximum cost-effectiveness. Interactive provider education is also a successful approach that is gaining acceptance as experience evolves. Performance feedback can be a powerful tool for improving antimicrobial prescribing patterns. This method is more likely to be acceptable when utilization in a unit is compared over time or to a benchmark; provider-specific performance feedback can be successfully implemented if initial resistance is overcome. Computerized decision support is likely to be the best long-term approach for improving antimicrobial use. Effective and Increasingly Used Resource intensive up front Link to: SHEA / IDSA: Guidelines for the Prevention of Antimicrobial Resistance in Hospitals

5 Multi-prong approaches
Abx management teams Computerized systems

6 Which ASP component is most helpful?

7 Hospitalwide Program Bantar, CID, 2003 ASP No formulary restrictions
ID MD Clin Microbiologist Lab Microbiologist 2 Pharmacists IM MD No formulary restrictions

8 Hospitalwide Program 4 step intervention phased in every 6 mos Goal
Optional Antibiotic order forms Mandatory Abx forms with feedback Review of every Abx order and education Modification by AMT if necessary Goal Decrease 3rd gen Ceph Increase BL/Blase inhibitor

9 Hospitalwide Program

10 Hospitalwide Program

11 Hospitalwide Program Iams Vanco Icfp Iams Carb

12 Hospitalwide Program Cost savings occur most with mandatory ordering forms

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

14 Computerized Systems

15 Computerized Program Pestotnik, Annals IM, 1996 Evans, NEJM, 1998
LDS hospital Computerized guidelines Development Intergrated information History Labs Cultures Guidelines Abx choices Abx dosing Abx duration

16 Outcomes

17 Outcomes

18 Outcomes 76 % few adverse drug events

19 Longterm followup

20 Carling, 2003 Boston community hospital ASP program Outcomes Costs
Rates of C. difficile/ R GNR infection Antibiogram vs. NNIS data

21 Carling, 2003

22 Carling, 2003 VRE

23 Carling, 2003 Impact of ASP long-lasting Costs Nosocomial pathogens
Ability to handle new resistant pathogens

24 Local example of impact

25 Local

26 HCSD Beginnings Data ILH team HCSD ASP committee
Pharmacy and Utilization from ILH and HCSD systems offices MDRO from ILH and HCSD Quality Compass ILH team Xavier PharmD faculty (Brakta, Johnson, Bryant, Al-Dahir) ILH Pharmacy (Cardwell, Terry) ILH IC (Friloux, Bergeron) ILH Microbiology Lab (Wall) HCSD Pharmacy (Jackson) ID/IC Faculty (Hull, Maffei, Figueroa) CCM Faculty (deBoisBlanc) HCSD ASP committee ID chair (Brown) Similar personnel from other HCSD facilities

27 ILH ASP team

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

29 Antibiotic utilization

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

31

32

33

34 Length of Stay

35

36 Antibiotic Use by HCSD hospital

37

38

39

40 MDRO rates

41 ILH

42 Next Steps for ILH Implementation of cellulitis protocol
Daily review of broad spectrum Abx with de-escalation recommendations Prolonged beta-lactam dosing COPD/asthma protocol Limited microbiology Abx reporting Pharmacokinetic service for vancomycin and aminoglycosides

43 Outcomes tracked Broad spectrum Abx use
Length of stay for infectious disease diagnoses MDRO rates

44

45 Top 65 ICD9 codes by HCSD hospital

46

47 Jump!

48

49

50 3rd gen Ceph Restriction
Empey, 2002 1999 formulary change Cefepime for 3rd gen C Encourage BL/Blase combo Vanco 72 hr stop Retrospective Antibiogram 6 mos before and after change

51 3rd gen Ceph Restriction
Empey, 2002 1999 formulary change Cefepime for 3rd gen C Encourage BL/Blase combo Vanco 72 hr stop Retrospective Antibiogram 6 mos before and after change

52 Abx susceptibilities

53 Your results may vary! No decrease in monthly total abx costs
Shift to cefepime and carbepenem But decreased cephalosporin costs ($38K to $30K) Need to control carbepenem and cefepime use Avoid carbepenem-R Pseudomonas/ Acinetobacter Advocate for narrowness of spectrum

54 3rd gen Ceph Restriction
Du, CCM, 2003 Prospective study Peking, China ICU pts Before and after 3rd gen Ceph restriction ( ) Except Surg prophylaxis Switched to cefepime or carbepenem Outcomes of ICU infx 80 in 2000 (before) 83 in 2001 (after)

55 3rd gen Ceph Restriction
Du, CCM, 2003 Prospective study Peking, China ICU pts Before and after 3rd gen Ceph restriction ( ) Except Surg prophylaxis Switched to cefepime or carbepenem Outcomes of ICU infx 80 in 2000 (before) 83 in 2001 (after)

56 Total infection isolates

57 Abx resistance Total isolates 18 28 47 42

58 Outcomes Outcome Phase I (n 80) Phase II (n 83) ICU stay, days
29.3 ± 46.8 17.6 ± 14.8 Infx-related death 29 (36.3) 16 (19.3) Pseudomonas 19/47 (40.4) 6/42 (14.3) Acinetobacter 16/39 (41.0) 11/41 (26.8) Stenotrophomonas 8/20 (40.0) 4/20 (20.0) Ecoli and Kleb 4/18 (22.2) 2/28 (7.1) Enterobacter 9/21 (42.9) 4/9 (44.4) Cefepime S org 5/18 (27.8) 2/38 (5.3) Cefepime R org 24/62 (38.7) 14/45 (31.1)

59 Outcomes Outcome Phase I (n 80) Phase II (n 83) ICU stay, days
29.3 ± 46.8 17.6 ± 14.8 Infx-related death 29 (36.3) 16 (19.3) Pseudomonas 19/47 (40.4) 6/42 (14.3) Acinetobacter 16/39 (41.0) 11/41 (26.8) Stenotrophomonas 8/20 (40.0) 4/20 (20.0) Ecoli and Kleb 4/18 (22.2) 2/28 (7.1) Enterobacter 9/21 (42.9) 4/9 (44.4) Cefepime S org 5/18 (27.8) 2/38 (5.3) Cefepime R org 24/62 (38.7) 14/45 (31.1)

60 Outcomes Outcome Phase I (n 80) Phase II (n 83) ICU stay, days
29.3 ± 46.8 17.6 ± 14.8 Infx-related death 29 (36.3) 16 (19.3) Pseudomonas 19/47 (40.4) 6/42 (14.3) Acinetobacter 16/39 (41.0) 11/41 (26.8) Stenotrophomonas 8/20 (40.0) 4/20 (20.0) Ecoli and Kleb 4/18 (22.2) 2/28 (7.1) Enterobacter 9/21 (42.9) 4/9 (44.4) Cefepime S org 5/18 (27.8) 2/38 (5.3) Cefepime R org 24/62 (38.7) 14/45 (31.1)

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

62 Logistic Regression Risk Factor Odds Ratio 95% CI Infection with
E coli or Kleb 0.312 Restriction of 3rd gen C 0.384 Immuno-compromised 4.503 Pneumonia 9.788 CVVH 14.166

63 Formulary restrictions
3rd gen Cephalosporin restriction Decrease resistance Decrease costs ? Decrease mortality in ICUs ? Future questions Restriction of all cephalosporins Restriction of carbepenems Restriction of quinolones ? Restriction of anti-anaerobic Abx

64 Antibiotic management teams
Composed of: Clinical pharmacist ID specialist Microbiology lab representative Infection control representative

65 Antibiotic stewardship programs
Composed of: Clinical pharmacist ID specialist Microbiology lab representative Infection control representative Duties Education Practice guidelines for common diseases Formulary selections/restrictions Active surveillence and intervention Direct feedback

66 Results Gross, CID 2001 Multi-step program
Limited available formulary with many restrictions Treatment guidelines Team to approve restricted Abx Comparison of Team vs. ID fellow approvals on patients without ID consult (180 calls) in Nov 1993 Outcomes and Costs Appropriateness Cure Failure Costs

67 Results Gross, CID 2001 Multi-step program
Limited available formulary with many restrictions Treatment guidelines Team to approve restricted Abx Comparison of Team vs. ID fellow approvals on patients without ID consult (180 calls) in Nov 1993 Outcomes and Costs Appropriateness Cure Failure Costs

68 Multivariate analysis for appropriateness
Variable OR 95%CI ASP vs ID fellows 11.0 4.6-25 Surg vs. Medical team 0.41 Other vs. Medical team 0.39 Oncological comorbidity Neurological comorbidity 0.21

69 Multivariate analysis for treatment failure
Variable OR 95%CI ASP vs ID fellows 0.5 GI comorbid 3.9 ICU stay 4.8 Sepsis 3.6

70 Factors making recommendations inappropriate
ASP ID Fellow OR 95%CI Cost 6 25 0.2 Too broad 4 21 Too narrow 1 5 0-1.4 Inapprop spectrum 14 0.1 0-0.4 Not indicated 9 0.7 0.2-2 Route inapprop 2 Dose inapprop

71 Factors making recommendations inappropriate
ASP ID Fellow OR 95%CI Cost 6 25 0.2 Too broad 4 21 Too narrow 1 5 0-1.4 Inapprop spectrum 14 0.1 0-0.4 Not indicated 9 0.7 0.2-2 Route inapprop 2 Dose inapprop

72 Factors making recommendations inappropriate
ASP ID Fellow OR 95%CI Cost 6 25 0.2 Too broad 4 21 Too narrow 1 5 0-1.4 Inappropriate spectrum 14 0.1 0-0.4 Not indicated 9 0.7 0.2-2 Route inapprop 2 Dose inapprop

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

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

75 Methods to Improve Antimicrobial Use
12 Steps to Prevent Antimicrobial Resistance: Hospitalized Adults Step 5: Practice antimicrobial control Methods to Improve Antimicrobial Use Passive prescriber education Passive education of healthcare personnel is probably the least effective strategy for improving antimicrobial use, but does have some impact. Strategies designed to limit use, including antimicrobial order forms, formulary restrictions, and approval systems, can be successful, but only if resources are applied to ensure oversight and response. Automatic pharmacy substitution of one similar drug for another or from one route of administration to another (e.g. IV to oral) can be highly successful in reducing costs, but is not always acceptable to clinicians. Multidisciplinary drug utilization evaluation is an approach favored in institutions that have successfully engaged the appropriate professionals in the process, but does require up-front personnel resources to have maximum cost-effectiveness. Interactive provider education is also a successful approach that is gaining acceptance as experience evolves. Performance feedback can be a powerful tool for improving antimicrobial prescribing patterns. This method is more likely to be acceptable when utilization in a unit is compared over time or to a benchmark; provider-specific performance feedback can be successfully implemented if initial resistance is overcome. Computerized decision support is likely to be the best long-term approach for improving antimicrobial use. Link to: SHEA / IDSA: Guidelines for the Prevention of Antimicrobial Resistance in Hospitals

76 Methods to Improve Antimicrobial Use
12 Steps to Prevent Antimicrobial Resistance: Hospitalized Adults Step 5: Practice antimicrobial control Methods to Improve Antimicrobial Use Passive prescriber education Least Effective Strategy Passive education of healthcare personnel is probably the least effective strategy for improving antimicrobial use, but does have some impact. Strategies designed to limit use, including antimicrobial order forms, formulary restrictions, and approval systems, can be successful, but only if resources are applied to ensure oversight and response. Automatic pharmacy substitution of one similar drug for another or from one route of administration to another (e.g. IV to oral) can be highly successful in reducing costs, but is not always acceptable to clinicians. Multidisciplinary drug utilization evaluation is an approach favored in institutions that have successfully engaged the appropriate professionals in the process, but does require up-front personnel resources to have maximum cost-effectiveness. Interactive provider education is also a successful approach that is gaining acceptance as experience evolves. Performance feedback can be a powerful tool for improving antimicrobial prescribing patterns. This method is more likely to be acceptable when utilization in a unit is compared over time or to a benchmark; provider-specific performance feedback can be successfully implemented if initial resistance is overcome. Computerized decision support is likely to be the best long-term approach for improving antimicrobial use. Link to: SHEA / IDSA: Guidelines for the Prevention of Antimicrobial Resistance in Hospitals

77 Methods to Improve Antimicrobial Use
12 Steps to Prevent Antimicrobial Resistance: Hospitalized Adults Step 5: Practice antimicrobial control Methods to Improve Antimicrobial Use Passive prescriber education Standardized antimicrobial order forms Formulary restrictions Prior approval to start/continue Passive education of healthcare personnel is probably the least effective strategy for improving antimicrobial use, but does have some impact. Strategies designed to limit use, including antimicrobial order forms, formulary restrictions, and approval systems, can be successful, but only if resources are applied to ensure oversight and response. Automatic pharmacy substitution of one similar drug for another or from one route of administration to another (e.g. IV to oral) can be highly successful in reducing costs, but is not always acceptable to clinicians. Multidisciplinary drug utilization evaluation is an approach favored in institutions that have successfully engaged the appropriate professionals in the process, but does require up-front personnel resources to have maximum cost-effectiveness. Interactive provider education is also a successful approach that is gaining acceptance as experience evolves. Performance feedback can be a powerful tool for improving antimicrobial prescribing patterns. This method is more likely to be acceptable when utilization in a unit is compared over time or to a benchmark; provider-specific performance feedback can be successfully implemented if initial resistance is overcome. Computerized decision support is likely to be the best long-term approach for improving antimicrobial use. Link to: SHEA / IDSA: Guidelines for the Prevention of Antimicrobial Resistance in Hospitals

78 Methods to Improve Antimicrobial Use
12 Steps to Prevent Antimicrobial Resistance: Hospitalized Adults Step 5: Practice antimicrobial control Methods to Improve Antimicrobial Use Passive prescriber education Standardized antimicrobial order forms Formulary restrictions Prior approval to start/continue Successful, but only if resources to ensure oversight Passive education of healthcare personnel is probably the least effective strategy for improving antimicrobial use, but does have some impact. Strategies designed to limit use, including antimicrobial order forms, formulary restrictions, and approval systems, can be successful, but only if resources are applied to ensure oversight and response. Automatic pharmacy substitution of one similar drug for another or from one route of administration to another (e.g. IV to oral) can be highly successful in reducing costs, but is not always acceptable to clinicians. Multidisciplinary drug utilization evaluation is an approach favored in institutions that have successfully engaged the appropriate professionals in the process, but does require up-front personnel resources to have maximum cost-effectiveness. Interactive provider education is also a successful approach that is gaining acceptance as experience evolves. Performance feedback can be a powerful tool for improving antimicrobial prescribing patterns. This method is more likely to be acceptable when utilization in a unit is compared over time or to a benchmark; provider-specific performance feedback can be successfully implemented if initial resistance is overcome. Computerized decision support is likely to be the best long-term approach for improving antimicrobial use. Link to: SHEA / IDSA: Guidelines for the Prevention of Antimicrobial Resistance in Hospitals

79 Methods to Improve Antimicrobial Use
12 Steps to Prevent Antimicrobial Resistance: Hospitalized Adults Step 5: Practice antimicrobial control Methods to Improve Antimicrobial Use Passive prescriber education Standardized antimicrobial order forms Formulary restrictions Prior approval to start/continue Successful, but only if resources to ensure oversight Passive education of healthcare personnel is probably the least effective strategy for improving antimicrobial use, but does have some impact. Strategies designed to limit use, including antimicrobial order forms, formulary restrictions, and approval systems, can be successful, but only if resources are applied to ensure oversight and response. Automatic pharmacy substitution of one similar drug for another or from one route of administration to another (e.g. IV to oral) can be highly successful in reducing costs, but is not always acceptable to clinicians. Multidisciplinary drug utilization evaluation is an approach favored in institutions that have successfully engaged the appropriate professionals in the process, but does require up-front personnel resources to have maximum cost-effectiveness. Interactive provider education is also a successful approach that is gaining acceptance as experience evolves. Performance feedback can be a powerful tool for improving antimicrobial prescribing patterns. This method is more likely to be acceptable when utilization in a unit is compared over time or to a benchmark; provider-specific performance feedback can be successfully implemented if initial resistance is overcome. Computerized decision support is likely to be the best long-term approach for improving antimicrobial use. 40% of hospitals with restricted formulary 60% of hospitals with automatic stops Link to: SHEA / IDSA: Guidelines for the Prevention of Antimicrobial Resistance in Hospitals

80 Just say no! Associated with: MDR GNR MRSA VRE C. difficile 3rd gen
Cephalosporins

81 Just say no! Associated with: MDR GNR Quinolone R GNR Quinolone R Spn
MRSA C. difficile Quinolones

82 Just say no! Associated with: VRE Concern for VISA Concern for VRSA
Vancomycin

83 Methods to Improve Antimicrobial Use
12 Steps to Prevent Antimicrobial Resistance: Hospitalized Adults Step 5: Practice antimicrobial control Methods to Improve Antimicrobial Use Passive prescriber education Standardized antimicrobial order forms Formulary restrictions Prior approval to start/continue Pharmacy substitution or switch Passive education of healthcare personnel is probably the least effective strategy for improving antimicrobial use, but does have some impact. Strategies designed to limit use, including antimicrobial order forms, formulary restrictions, and approval systems, can be successful, but only if resources are applied to ensure oversight and response. Automatic pharmacy substitution of one similar drug for another or from one route of administration to another (e.g. IV to oral) can be highly successful in reducing costs, but is not always acceptable to clinicians. Multidisciplinary drug utilization evaluation is an approach favored in institutions that have successfully engaged the appropriate professionals in the process, but does require up-front personnel resources to have maximum cost-effectiveness. Interactive provider education is also a successful approach that is gaining acceptance as experience evolves. Performance feedback can be a powerful tool for improving antimicrobial prescribing patterns. This method is more likely to be acceptable when utilization in a unit is compared over time or to a benchmark; provider-specific performance feedback can be successfully implemented if initial resistance is overcome. Computerized decision support is likely to be the best long-term approach for improving antimicrobial use. Link to: SHEA / IDSA: Guidelines for the Prevention of Antimicrobial Resistance in Hospitals

84 Methods to Improve Antimicrobial Use
12 Steps to Prevent Antimicrobial Resistance: Hospitalized Adults Step 5: Practice antimicrobial control Methods to Improve Antimicrobial Use Passive prescriber education Standardized antimicrobial order forms Formulary restrictions Prior approval to start/continue Pharmacy substitution or switch Can reduce costs But not always accepted by MDs Passive education of healthcare personnel is probably the least effective strategy for improving antimicrobial use, but does have some impact. Strategies designed to limit use, including antimicrobial order forms, formulary restrictions, and approval systems, can be successful, but only if resources are applied to ensure oversight and response. Automatic pharmacy substitution of one similar drug for another or from one route of administration to another (e.g. IV to oral) can be highly successful in reducing costs, but is not always acceptable to clinicians. Multidisciplinary drug utilization evaluation is an approach favored in institutions that have successfully engaged the appropriate professionals in the process, but does require up-front personnel resources to have maximum cost-effectiveness. Interactive provider education is also a successful approach that is gaining acceptance as experience evolves. Performance feedback can be a powerful tool for improving antimicrobial prescribing patterns. This method is more likely to be acceptable when utilization in a unit is compared over time or to a benchmark; provider-specific performance feedback can be successfully implemented if initial resistance is overcome. Computerized decision support is likely to be the best long-term approach for improving antimicrobial use. Link to: SHEA / IDSA: Guidelines for the Prevention of Antimicrobial Resistance in Hospitals

85 Methods to Improve Antimicrobial Use
12 Steps to Prevent Antimicrobial Resistance: Hospitalized Adults Step 5: Practice antimicrobial control 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 Passive education of healthcare personnel is probably the least effective strategy for improving antimicrobial use, but does have some impact. Strategies designed to limit use, including antimicrobial order forms, formulary restrictions, and approval systems, can be successful, but only if resources are applied to ensure oversight and response. Automatic pharmacy substitution of one similar drug for another or from one route of administration to another (e.g. IV to oral) can be highly successful in reducing costs, but is not always acceptable to clinicians. Multidisciplinary drug utilization evaluation is an approach favored in institutions that have successfully engaged the appropriate professionals in the process, but does require up-front personnel resources to have maximum cost-effectiveness. Interactive provider education is also a successful approach that is gaining acceptance as experience evolves. Performance feedback can be a powerful tool for improving antimicrobial prescribing patterns. This method is more likely to be acceptable when utilization in a unit is compared over time or to a benchmark; provider-specific performance feedback can be successfully implemented if initial resistance is overcome. Computerized decision support is likely to be the best long-term approach for improving antimicrobial use. Link to: SHEA / IDSA: Guidelines for the Prevention of Antimicrobial Resistance in Hospitals

86 Hospitalwide Program 4 step intervention phased in every 6 mos Goal
Optional Antibiotic order forms Mandatory Abx forms with feedback Review of every Abx order and education Modification by AMT if necessary Goal Decrease 3rd gen Ceph Increase BL/Blase inhibitor

87 Hospitalwide Program Ratios of preferred abx to 3rd gen Ceph
Iams = aminopen/sulbactam to 3rd gen Ceph Icfp = cefepime to 3rd gen Ceph

88 Methods to Improve Antimicrobial Use
12 Steps to Prevent Antimicrobial Resistance: Hospitalized Adults Step 5: Practice antimicrobial control 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 Passive education of healthcare personnel is probably the least effective strategy for improving antimicrobial use, but does have some impact. Strategies designed to limit use, including antimicrobial order forms, formulary restrictions, and approval systems, can be successful, but only if resources are applied to ensure oversight and response. Automatic pharmacy substitution of one similar drug for another or from one route of administration to another (e.g. IV to oral) can be highly successful in reducing costs, but is not always acceptable to clinicians. Multidisciplinary drug utilization evaluation is an approach favored in institutions that have successfully engaged the appropriate professionals in the process, but does require up-front personnel resources to have maximum cost-effectiveness. Interactive provider education is also a successful approach that is gaining acceptance as experience evolves. Performance feedback can be a powerful tool for improving antimicrobial prescribing patterns. This method is more likely to be acceptable when utilization in a unit is compared over time or to a benchmark; provider-specific performance feedback can be successfully implemented if initial resistance is overcome. Computerized decision support is likely to be the best long-term approach for improving antimicrobial use. Link to: SHEA / IDSA: Guidelines for the Prevention of Antimicrobial Resistance in Hospitals

89 Computerized Antimicrobial Decision Support
12 Steps to Prevent Antimicrobial Resistance: Hospitalized Adults Step 5: Practice antimicrobial control 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 mortality 3.65% 2.65% Antimicrobial cost per treated patient $ $51.90 Properly timed preoperative antimicrobial 40% 99.1% Stable antimicrobial resistance Adverse drug events decreased by 30% In this study of patients admitted to a community hospital in Salt Lake City, Utah, computer-assisted decision support was successfully employed to guide antimicrobial treatment. Over a 7-year period of time after the system was implemented, the acuity of patients admitted to the hospital increased. However, hospital mortality, antimicrobial treatment costs per patient, and adverse drug events declined. The proportion of patients who received a properly-timed preoperative prophylactic antimicrobial increased dramatically. Overall, patterns of antimicrobial resistance were stable over the 7-year study period. Source: Pestotnik SL, et al: Ann Intern Med 1996;124:884-90

90 Computerized Program Evans, NEJM, 1998 ICU patients
Pre-intervention Open formulary Baseline Intervention Computer program Could reject Had to explain deviation from recommendations Outcomes Cost Quality of care

91 Computerized Systems Advantages Disadvantages
All information available immediately (save time) Shorter patient LOS (save money) Put guidelines into place (save patients; save antibiotics) Disadvantages Costly, complicated system to maintain with intergration of multiple sources of information Removes autonomy ?

92

93 Pharm

94 Pharm Micro

95 ID/IC Pharm Micro

96 ID/IC Pharm Micro MD


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