1. Strategies for Implementing Antimicrobial Stewardship Guidelines
Ann Biehl, M.S., Pharm.D.
PGY1 Pharmacy Resident
McLeod Regional Medical Center
Florence, South Carolina
South Carolina Society of Health-System Pharmacists
Spring Symposium 2008
Myrtle Beach, South Carolina
Talk until not nervous 1

2. Objectives Identify current antimicrobial practice guidelines
Discuss strategies for complying with practice standards 2 2

3. Antimicrobial Resistance: a growing problem
In 2004, approximately 2 million people experienced a hospital-acquired infection
90,000 of these infections were fatal
1 death every six minutes
70% of these infections were resistant to at least one drug
The clock is ticking…
Dellit TH. Clin Infect Dis 2007 Jan 15;44(2):159 3 3

4. It has been well documented in the literature that overuse of antibiotics has led to increases in resistance
And resistant strains spread rapidly
MRSA 60% of s. aureus isolates are methicillin resistant
The estimated rate of invasive MRSA in 2005 is greater than the rates of pneumococcal disease, group A strep, meningococcal disease, and H. influenzae combined.
30% of P. aero is resistant to FQ
Little less than 30% of enterococci are vancomycin resistant 4
Accessed from February 1, 2008. 4

5. Infectious Diseases Society of America Superbug Hit List
Methicillin-resistant Staphylococcus aureus
Vancomycin-resistant Enterococcus faecium (VRE)
Escherichia coli
Klebsiella species
Pseudomonas aeruginosa
Acinetobacter baumannii
THE HIT LIST:
Methicillin-resistant Staphylococcus aureus (MRSA): MRSA infections constitute the majority of health care-associated infections, increasing lengths of hospital stay, severity of illness, deaths, and costs. While these infections used to be limited primarily to hospitals, they are becoming increasingly common in communities nationwide, especially where groups of people are in close quarters, including military facilities, sports teams, and prisons. The number of infected children jumped 28 percent between 2001 and Several treatment options are available for MRSA, but many have harsh side effects, and resistance is growing to each of them. Most of the drugs in development must be given by injection—a painful, inconvenient, and expensive route. Drugs that can be taken by mouth are desperately needed.
Escherichia coli and Klebsiella species: These bacteria are major causes of urinary tract, gastrointestinal tract, and wound infections. They are becoming resistant to a growing number of antibiotic classes at the same time as the frequency of outbreaks is increasing. Failure to treat with the appropriate antibiotics during a recently documented K. pneumoniae outbreak increased the mortality rate from 14 percent to 64 percent Both microbes tend to rapidly evolve resistance to new drugs, but few are available or under development. New therapies are badly needed. Acinetobacter baumannii:A. baumannii "is a prime example of a mismatch between unmet medical need and the current antimicrobial research and development pipeline," according to the Clinical Infectious Diseases article. The bacterium is a growing cause of hospital-acquired pneumonia. Mortality rates range from 20 to 50 percent. The number and hardiness of drug- resistant strains are growing. Soldiers are also returning from Iraq and Afghanistan with cases of highly resistant Acinetobacter wound infections Doctors have been forced to resort to an old drug, colistin, which had previously been abandoned as too toxic. But only one new drug is on the horizon to treat Acinetobacter infections, and it is considered to be too toxic for children.
Vancomycin-resistant Enterococcus faecium (VRE): VRE is a major cause of bloodstream infections, infections of the heart, meningitis, and intra-abdominal infections. A recent survey of U.S. hospitals found a VRE rate of 10 percent of across all patient groups. Rates are as high as 70 percent among high-risk groups While drugs are available to treat VRE, they have serious shortcomings. Current drugs do not rapidly kill VRE, and only one is available in an oral formulation Pseudomonas aeruginosa: This germ causes severe infection that can be life-threatening, particularly in immunocompromised patients. Rates of P. aeruginosa hospital-acquired pneumonia have nearly doubled, from 9.6 percent in 1975 to 18.1 percent in Infections following surgery and urinary tract infections from P. aeruginosa have doubled. The germ poses a particular threat to children with cystic fibrosis (CF). Antibiotics can keep CF patients alive for decades, but eventually highly resistant germs take over. With almost no alternatives left, these patients die unless they receive lung transplants No novel drug candidates have entered human trials. New ideas, research, and products are desperately needed. 5
Accessed from February 20, 2008 5

6. To compound the problem, the antibiotic drug pipeline is drying up.
Drug manufacturers are focusing more on the treatment of chronic conditions
The cost and time to bring a drug to market, estimated between 800 million and 1.7 billion and at 10 years, is becoming prohibitively high.
In 2002, out of 89 newly approved drugs, none were antimicrobials.
Currently no new gram negative classes in the pipeline
Accessed from February 1, 2008. 6 6

7. Antibacterials vs. Anti-HIV Agents7
Spellberg, et al. Clin Infect Dis 2008 Jan 15;46:000 7

8. New Legislation Food and Drug Administration Amendments Act (2007)
Strategies to Address Antimicrobial Resistance (STAAR) Act
Research and development tax credits for infectious disease products 8
Spellberg, et al. Clin Infect Dis 2008 Jan 15;46:000 8

9. Health care professionals are already playing
JEOPARDY
In a sense, we are addicted to antimicrobials. To the point where the cdc has developed a 12-step program….
with antimicrobials 9 9

10. The campaign centers on four main strategies:
prevent infection
diagnose and treat infection
use antimicrobials wisely
prevent transmission.
Within the context of these strategies, multiple 12-step programs are being developed targeting clinicians who treat specialty-specific patient populations including hospitalized adults, dialysis patients, surgical patients, hospitalized children, and long-term care patients.
How do we apply these principles?
Centers for Disease Control and Prevention (CDC) 12 steps to prevent antimicrobial resistance. 10 10

11. ? ? ? ? ?
The answer:
This activity can result in the best clinical outcome for the treatment OR prevention of infection with minimal toxicity and minimal impact on subsequent resistance. 11 11

12. Antimicrobial Stewardship? ? ? ? ?
What is:
Antimicrobial Stewardship ? ? ? 12 12

13. Antimicrobial Stewardship
Defined:
the optimal selection, dosage, route and
duration of antimicrobial treatment.
Defined as the optimal
Dellit TH. Clin Infect Dis 2007 Jan 15; 44(2):159 13 13

14. Review of Antimicrobial Stewardship
1997: IDSA and Society of Health Care Epidemiology of America publish guidelines for preventing and reducing antimicrobial resistance in hospitals
2002: CDC launches 12 steps
to prevent antimicrobial resistance in hospitalized adults campaign
2007: IDSA releases guidelines for developing institutional stewardship programs
1999: CDC, FDA, and NIH publish a public health action plan to combat antimicrobial resistance
2006: CDC releases Management of Multidrug-Resistant Organisms in Health Care Settings guidelines
Just in time? October 2008: Medicare will stop reimbursement for hospital-acquired conditions deemed preventable. Several of these conditions are infection-related.
Antimicrobial stewardship, is a term originally coined by Dr. Dale Gerding, Professor from the Department of Medicine at Loyola University Stritch School of Medicine (Chicago) and Associate Chief of Staff for Research & Development, Hines VA Hospital in Illinois, United States, ID specialist practicing for 39 years.
1997 and 1999 guidelines both stressed the importance of improving the use of antimicrobials (antimicrobial stewardship) at the institutional level in combating resistance
1999: a more global document addressing threat of resistance
October 2008: Medicaid will stop reimbursing for
vascular cathetar-associated infections
Mediastinitis post-CABG
Shales DM. Clin Infect Dis 1997;25:584 – 99
Bell D. In: Knobler SL, Lemon SM, Najafi M, Burroughs T, eds. Forum on emerging infections. Washington DC: National Academy Press, 2003.
Centers for Disease Control and Prevention (CDC) 12 steps to prevent antimicrobial resistance.
Siegel JD. Centers for Disease Control and Prev; 2006: 74
Dellit TH. Clin Infect Dis 2007 Jan 15;44(2):159 14 14

15. Antimicrobial Stewardship
Primary Goal: to optimize clinical outcomes while minimizing unintended consequences of antimicrobial use
Consequences
Toxicity
Selection of pathogenic organisms
Emergence of resistant pathogens
Secondary goal: to reduce health care costs without adversely affecting the quality of care 15
Dellit TH. Clin Infect Dis 2007 Jan 15;44(2):159 15

16. Aspects of antimicrobial stewardship applied…
Vancomycin resistant E faecium. Downloaded from December 17, 2007. 16

17. Results of an Antimicrobial Control Program
University of Kentucky Chandler Medical Center
Impact of first five years of an ongoing antimicrobial management program (1998 – 2002)
Report published in American Journal of Health-System Pharmacy in 2005 17
Martin et al. Am J Health-Sys Pharm 2005 Apr 1; 62: 17

18. Methods
Formed antimicrobial subcommittee within Pharmacy and Therapeutics committee
Representatives from surgery, pediatrics, internal medicine, transplantation, critical care, infectious disease, pharmacy and nursing 18
Martin et al. Am J Health-Sys Pharm 2005 Apr 1; 62: 18

19. Methods Subcommittee responsibilities
Develop and implement initiatives to ensure appropriate antimicrobial use
Review the existing formulary and recommend cost effective agents that may reduce the selection of resistant nosocomial pathogens 19
Martin et al. Am J Health-Sys Pharm 2005 Apr 1; 62: 19

20. Cephalosporins Ceftazidime and Cefotaxime removed from formulary
Association with increased risk of MDR gram negative organisms and VRE
Ceftriaxone limited to treatment of CAP, meningitis and UTIs
Penicillin regimens endorsed for most infections
Cefepime added for nosocomial infections in patients intolerant of PCNs
PCN  further reduce the use of cephalosporins
Example: Zosyn +/- aminoglycoside or FQ recommended to replace ceftazidime regimen for treatment of nosocomial pneumonia
Cefepime: especially for pseudomonas infections 20
Martin et al. Am J Health-Sys Pharm 2005 Apr 1; 62: 20

21. Vancomycin
Internal audit  poor compliance with CDC Hospital Infection Control Practices Advisory Committee (HICPAC) guidelines
CDC. Recommendations for preventing the spread of vancomycin resistance. MMWR 1995;44:RR-1
Mandatory 72-hour stop time unless “vancomycin continuation form” was completed on return of culture and sensitivity data
Agent was discontinued if patient did not meet criteria within 72 hours
ID consult required to override automatic discontinuation
HICPAC guidelines incorporated into a continuation form that was placed on chart
Medical teams notified of stop date by the pharmacist rounding with the team 21
Martin et al. Am J Health-Sys Pharm 2005 Apr 1; 62: 21

22. Fluoroquinolones
Levofloxacin replaced ciprofloxacin as formulary fluoroquinolone (May 2001)
Ciprofloxacin associated with resistance in multiple common pathogens
Cost to have both ciprofloxacin and levofloxacin on formulary prohibitively high
Cipro resistance in S. aureus and P. Aeroginosa
* Because both agents were on formulary the market share for each agent was below the best acquisition threshold. LQ only resulted in better price break and decreased expense. 22
Martin et al. Am J Health-Sys Pharm 2005 Apr 1; 62: 22

23. Carbapenems
Inappropriate use associated with MDR Pseudomonas aeroginosa and Acinetobacter baumannii
Use restricted to documented infections with extended-spectrum β-lactamase producing organism or organism otherwise resistant
Necessitating the use of more toxic drugs such as polymixin B and colistin
Orgs res to reasonable alternatives 23
Martin et al. Am J Health-Sys Pharm 2005 Apr 1; 62: 23

24. Amphotericin B formulations
All lipid formulations restricted
ID approval required before use
No clear therapeutic benefit demonstrated with these formulations vs. conventional formulations 24
Martin et al. Am J Health-Sys Pharm 2005 Apr 1; 62: 24

25. Monitoring
Susceptibility rates of key pathogens reported on quarterly by clinical microbiology laboratory
Antimicrobial expenditures reported on quarterly by the pharmacy financial officer
Compared with baseline (1998) and adjusted for inflation of drug acquisition costs
Purchases also monitored by defined daily doses/1000 patient days
DDDs were same as those used by Project ICARE; accounts for admission fluctuations 25
Martin et al. Am J Health-Sys Pharm 2005 Apr 1; 62: 25

26. Expenditures
1998 – 2002 expenditures decreased by 25% (total savings of $1,401,126)
Expected vs. actual antimicrobial expenditures adjusted for inflation and inpatient fluctuations..
Note the widening gap over time 26
Martin et al. Am J Health-Sys Pharm 2005 Apr 1; 62: 26

27. Antimicrobial Susceptibility and Resistance
Note: changes implemented in last quarter of 1999 27
Martin et al. Am J Health-Sys Pharm 2005 Apr 1; 62: 27

28. Antimicrobial Susceptibility and Resistance
MRSA resistance peaked at 40% in 1999 but has decreased by an average of 3% per year since that time 28
Martin et al. Am J Health-Sys Pharm 2005 Apr 1; 62: 28

29. Antimicrobial Susceptibility and Resistance
Ceftazidime resistance in K. pneumo has decreased dramatically since being removed from the formulary
DDDs as used in Project ICARE (Intensive Care Antimicrobial Resistance Epidemiology at Emory University) 29
Martin et al. Am J Health-Sys Pharm 2005 Apr 1; 62: 29

30. Tools for Success Multidisciplinary team
Periodic feedback to physicians regarding program’s benefits
Focused goals
Multidisciplinary team = incr physician acceptance of reccs
Periodic feedback to physicians regarding the benefits of the program = increased physician buy-in
Interventions targeted only at antibiotics that were being inappropriately used as determined by prior audit  program not perceived as punitive or interfering with autonomy 30
Martin et al. Am J Health-Sys Pharm 2005 Apr 1; 62: 30

31. Back to the guidelines. . .
Centers for Disease Control Guidelines for Multidrug-Resistant Organisms in Healthcare Settings (2006). Siegel JD. Centers for Disease Control and Prev; 2006: 74
Infectious Disease Society of America Guidelines for Developing Institutional Programs to Enhance Antimicrobial Stewardship
Dellit TH. Clin Infect Dis 2007 Jan 15;44(2):159 31 31

32. Centers for Disease Control Guidelines for Multidrug-Resistant Organisms in Healthcare Settings (2006)
Developed by experts in infection control in conjunction with CDC's Healthcare Infection Control Practices Advisory Committee (HICPAC)
Stresses the causal relationship between antibiotic use and resistance patterns
CDC MRDO guidelines address the judicious use of antimicrobial agents in the setting of a temporal association between formulary changes and decreased occurrence of MDROs in several studies. 32
Siegel JD. Centers for Disease Control and Prev; 2006: 74 32

33. Staffing and funding for prevention programs Track infection rates
Centers for Disease Control Guidelines for Multidrug-Resistant Organisms in Healthcare Settings (2006)
Staffing and funding for prevention programs
Track infection rates
Use standard infection control practices
Advocates that hospitals:
Ensure prevention programs are funded and adequately staffed
Track infection rates to monitor the impact of prevention efforts
Use standard infection control practices
Follow guidelines regarding the correct use of antibiotics
Utilize health education campaigns to increase adherence to established recommendations
Design prevention programs customized to specific settings and local needs 33
Siegel JD. Centers for Disease Control and Prev; 2006: 74 33

34. Follow guidelines regarding the correct use of antibiotics
Centers for Disease Control Guidelines for Multidrug-Resistant Organisms in Healthcare Settings (2006)
Follow guidelines regarding the correct use of antibiotics
Role of health education campaigns  increased adherence
Prevention programs customized to specific settings/ local needs 34
Siegel JD. Centers for Disease Control and Prev; 2006: 74 34

35. Infectious Disease Society of America Guidelines for Developing Institutional Programs to Enhance Antimicrobial Stewardship
Published in the official journal of the IDSA: Clinical Infectious Diseases
Includes IDSA ranking system for clinical guidelines
Contains recommendations for hospital-based stewardship programs (no outpatient recommendations) 35
Dellit TH. Clin Infect Dis 2007 Jan 15;44(2):159 35

36. Antimicrobial Stewardship Programs
Evidence Based
Improve patient
safety
Antimicrobial Stewardship Programs
Improve community
resistance profiles
Financially
self-supporting
Dellit TH. Clin Infect Dis 2007 Jan 15;44(2):159

37. IDSA Guidelines: Elements of a successful stewardship program
Comprehensive program
Active monitoring of resistance
Fostering of appropriate use
Often used as a surrogate marker for impact on resistance
Collaboration of effective infection control to minimize secondary spread of resistance
Three-pronged program designed to monitor and reduce the incidence and spread of bacterial resistance.
Evidence-based programs include elements of the following strategies based on local antimicrobial use and resistance patterns. 37
Dellit TH. Clin Infect Dis 2007 Jan 15;44(2):159 37

38. IDSA Guidelines: Collaborative effort
Multidisciplinary team
Core members include infectious disease physician (usually the director of the program) and clinical pharmacist with infectious disease training
Support from administration and medical staff leadership are integral to program’s success
Also need support of clinical microbiology, information systems, infection control, and hospital epidemiology 38
Rybak M. Pharmacotherapy; 27:131S 38

39. Infectious Disease Pharmacist
Qualifications
Pharm.D. degree
PGY1 Pharmacy Residency
Additional training in infectious diseases
ID specialty residency preferred
Maintain current knowledge base
Dellit TH. Clin Infect Dis 2007 Jan 15;44(2):159
Rapp R. 41st ASHP Midyear Clinical Meeting, 2006. 39 39

40. Infectious Disease Pharmacist
Duties
Provide interventional feedback for antimicrobial therapies
Collaborate with infectious disease physician
Follow clinical outcomes
Provide pharmacokinetic services
Monitor antimicrobial therapy for appropriate use and provide interventional feedback
Discuss order changes/recommendations with infectious disease physician
Follow clinical outcomes
Provide pharmacokinetic services
Educate hospital staff on appropriate antibiotic usage
Review antibiogram regularly
Precept and mentor pharmacy students, pharmacy practice residents and infectious disease specialty residents
Dellit TH. Clin Infect Dis 2007 Jan 15;44(2):159
Rapp R. 41st ASHP Midyear Clinical Meeting, 2006 40 40

41. Infectious Disease Pharmacist
Duties, con’t
Educate hospital staff on appropriate antibiotic usage
Precept and mentor pharmacy students, pharmacy practice residents and infectious disease specialty residents
Review antibiogram regularly
Dellit TH. Clin Infect Dis 2007 Jan 15;44(2):159
Rapp R. 41st ASHP Midyear Clinical Meeting, 2006 41 41

42. IDSA Guidelines: Key Recommendations
Two proactive core strategies:
Prospective audit with intervention and feedback to prescriber
Formulary restriction and preauthorization
Strategies are not mutually exclusive!!! Can use both
Prospective audit by ID physician or clinical pharmacist with ID training
Prospective audit: level A1 (RCTs to support) 42
Dellit TH. Clin Infect Dis 2007 Jan 15;44(2):159 42

43. Prospective Audit ID pharmacist and physician work together
Select drugs and units
Review cases and make recommendations within certain time frame after drug is ordered
Appropriate drug
Bug-drug
Streamlining/de-escalation
Dose
Route
Streamlining/deescalation
Can narrow therapy based on culture results. Elimination of redundant therapies can better target the causative pathogen
Dose optimization: increase patient safety and cost savings
IV to PO conversion: Development of a systemic plan with set clinical criteria and guidelines for IV to PO conversion can decrease length of stay and health care costs
Communication through written removable notes in chart 43
Dellit TH. Clin Infect Dis 2007 Jan 15;44(2):159 43

44. Formulary Restriction and Preauthorization
Stewardship team works closely with Pharmacy and Therapeutics Committee to designate restricted drugs and evidence-based indications
Pager for authorization
Success depends on who is authorizing
Challenges:
May shift resistance to alternative agent
Must monitor trends
Formulary restriction can be permanent or event driven (is level A-2  evidence from >1 properly designed clinical trial)
e.g. restricting clindamycin use during c.diff outbreaks  prompt cessation of the outbreak
Success depends on who is making recommendations
Program requiring prior authorization from a chief resident or attending physician had no impact on use BUT
Recommendations from an antimicrobial team of ID physician and pharmacist resulted in increased antimicrobial awareness, increased clinical cure, and trend towards improved economic outcomes vs. recommendations made by ID fellows.
Shift of resistance: squeezing the balloon, so to speak. 44
Dellit TH. Clin Infect Dis 2007 Jan 15;44(2):159 44

45. IDSA Guidelines: Additional Recommendations (Level A)
Education
Essential, but insufficient alone
Development of guidelines and clinical pathways
Can improve utilization
Can decrease amount of critical thinking
Passive Strategies:
Education: most frequently employed intervention and is essential to program success, but marginally effective without the incorporation of active interventions.
Guidelines and clinical pathways can improve utilization, but can decrease the amount of critical thinking…ex. MRMC pneumonia pathway with TB or PCP (every gets LQ!) 45
Dellit TH. Clin Infect Dis 2007 Jan 15;44(2):159 45

46. IDSA Guidelines: Additional Recommendations (Level A)
Streamlining or de-escalation of therapy
Dose optimization
Parenteral to oral conversion
Can narrow therapy based on culture results and elimination of redundant therapies can better target the causative pathogen
Dose optimization: increase patient safety and increase cost savings
IV to PO: can decrease length of stay and health care costs 46
Dellit TH. Clin Infect Dis 2007 Jan 15;44(2):159 46

47. IDSA Guidelines: Additional Recommendations (Level A)
Optimization of health care information technology
Integral role of clinical microbiology lab for rapid return of cultures and sensitivities and trend surveillance
Health care information:
includes CPOE (great improver of pt safety)
clinical decision support to review for allergies, DDIs, and recommend dosage regimens based on hepatic and renal function.
Targeting to use pharmacy records to ID patients on broad spectrum abx or expensive abx.
Micro lab: provides pt-specific data to optimize individual management and by assisting infection control in MDRO surveillance and epidemiological investigations of outbreaks. 47
Dellit TH. Clin Infect Dis 2007 Jan 15;44(2):159 47

48. IDSA Guidelines: Additional Recommendations (Levels B & C)
Antimicrobial order forms
may be an effective component of stewardship
Computer-based surveillance
increased efficiency in targeting interventions, tracking resistance patterns, and identifying nosocomial infections
Order forms:
Decrease consumption through use of automatic stop dates and physician justification
Successful use in perioperative antibiotic prophylaxis before new guidelines published  decrease in mean days of ppx from 4.9 to 2.4 days
Should not replace clinical judgement and renewal requirements should be clearly communicated to providers to avoid inappropiate treatment interruptions 48
Dellit TH. Clin Infect Dis 2007 Jan 15;44(2):159 48

49. IDSA Guidelines: Additional Recommendations (Levels B & C)
Antimicrobial cycling: insufficient data; not recommended
Combination therapy: role in certain clinical contexts but routine use not recommended
Monitor process and outcome measures to determine impact of stewardship program
Cycling:
CDC funded studies several years back revealed issues with antimicrobial cycling:
no way to know adequate cycle length
each pathogen has a different propensity for resistance based on
Antimicrobial pressure and mutation frequency…therefore, all pathogens should be on surveillance during the cycling period
Absolves the physician of analyzing the situation and making the most appropriate decision
Like telling an alcoholic to drink beer for 3 months, wine for 3 months, bourbon for 3 months, etc.
Combination therapy: appropriate if high organism burden combined with high frequency of mutation during therapy (e.g. TB, HIV)
Process measures: was the recommendation accepted?
Outcome measures: did the process implemented reduce or prevent resistance or other unintended consequences of antimicrobial use? 49
Dellit TH. Clin Infect Dis 2007 Jan 15;44(2):159 49

50. Determining the Impact of Stewardship
Process Measure: Did the intervention result in the desired change in antimicrobial use?
Process Goal: To change the use of a specific antimicrobial or drug class
Outcome Measure: Did the process implemented reduce or prevent resistance or other unintended consequences?
Outcome Goal: To reduce or prevent resistance or other unintended consequences of antimicrobial use 50 50

51. Antibiotic Order Front End Components Prior Authorization
Health care information technology/clinical decision support
Guidelines/order sets
Antibiotic Order
Both methods require the additional support of pharmacists!
Back End Components
Feedback audit
Streamlining/de-escalation
Dose optimization
IV to PO conversion 51 51

52. Future Directions Antimicrobial cycling
Clinical validation of heterogeneous use theory
Long-term impact of programs
Bundled programs
Effectiveness in subpopulations
Molecular epidemiology to understand the resistance gene pool
Automated surveillance strategies for nosocomial infections
Incorporation of stewardship into CPOE 52
Dellit TH. Clin Infect Dis 2007 Jan 15;44(2):159 52

53. Getting Started IDSA practice guideline Assess current climate of use
Clin Infect Dis 2007 Jan 15;44(2):159
Assess current climate of use
Identify potential barriers
Develop proposal
Present proposal to P&T; develop stewardship subcommittee with other hospital team members
Assess current climate of use (MRMC  survey)
Pharmacy director and ID chair develop budget proposal 53 53

54. McLeod Health Survey 54 54

55. Getting Started IDSA practice guideline Assess current climate of use
Clin Infect Dis 2007 Jan 15;44(2):159
Assess current climate of use
Identify potential barriers
Develop proposal
Present proposal to P&T; develop stewardship subcommittee with other hospital team members
Assess current climate of use (MRMC  survey)
Pharmacy director and ID chair develop budget proposal 55 55

56. Getting Started Hire ID physician and pharmacist Develop guidelines
Educate medical staff
Obtain physician buy-in
Implement changes
Track outcomes
What if the hospital cannot afford a full-time ID physician and ID pharmacist?
Part-time, select drugs, prolonged durations, etc. 56
Dellit TH. Clin Infect Dis 2007 Jan 15;44(2):159 56

57. Getting Started: Smaller Institutions
Scaled-down model
LaRocco A. Clin Infect Dis 2003; 37:742-3
ID physician and clinical pharmacist employed part-time
Reviewed patients receiving
Multiple
Prolonged
High-cost courses of therapy
69% of recommendations accepted
Cost savings estimated at $177,000
Many of the standards set forth in the IDSA guidelines can be modified to fit smaller institutions
Scaled down models can still have significant impact  120-bed community hospital employed stewardship team 3 days/week 57 57

58. STEWARDSHIP JEOPARDY! 58 58

59. JEOPARDY!
$100 59 59

60. JEOPARDY!
The answer:
The only class of drugs where use in one patient may alter future efficacy in another patient. 60 60

61. What are antimicrobials?
JEOPARDY!
What are antimicrobials? 61 61

62. JEOPARDY!
$200 62 62

63. JEOPARDY! The answer: Prevent transmission Use antimicrobials wisely
Diagnose and treat effectively
Prevent infections 63 63

64. JEOPARDY!
What are the major components to the CDC’s 12 steps to reduce antibiotic resistance? 64 64

65. JEOPARDY!
$300 65 65

66. JEOPARDY!
The answer:
A surrogate marker often used by antimicrobial stewardship programs to predict the avoidable impact on community resistance profiles. 66 66

67. What is inappropriate antibiotic use?
JEOPARDY!
What is inappropriate antibiotic use? 67 67

68. JEOPARDY!
$400 68 68

69. JEOPARDY!
The answer:
A core strategy of the IDSA guidelines that allows clinicians to order antibiotics without prior authorization but intervention can occur following treatment initiation. 69 69

70. What is prospective review and intervention?
JEOPARDY!
What is prospective review and intervention? 70 70

71. JEOPARDY!
$500 71 71

72. JEOPARDY!
The answer:
A significant benefit to antimicrobial stewardship programs that results in many programs being self-supporting. 72 72

73. JEOPARDY!
What is cost-savings? 73 73

74. JEOPARDY!
$600 74 74

75. JEOPARDY!
The answer:
This person contributes to the stewardship team by providing interventional feedback to physicians, working closely with the infectious disease physician, providing pharmacokinetic services, and educating hospital staff on appropriate antibiotic use.
Monitor antimicrobial therapy for appropriate use and provide interventional feedback
Discuss order changes/recommendations with infectious disease physician
Follow clinical outcomes
Provide pharmacokinetic services
Educate hospital staff on appropriate antibiotic usage
Review antibiogram regularly
Precept and mentor pharmacy students, pharmacy practice residents and infectious disease specialty residents 75 75

76. Who is the infectious disease pharmacist?
JEOPARDY!
Who is the infectious disease pharmacist?
Monitor antimicrobial therapy for appropriate use and provide interventional feedback
Discuss order changes/recommendations with infectious disease physician
Follow clinical outcomes
Provide pharmacokinetic services
Educate hospital staff on appropriate antibiotic usage
Review antibiogram regularly
Precept and mentor pharmacy students, pharmacy practice residents and infectious disease specialty residents 76 76

77. JEOPARDY!
$700 77 77

78. JEOPARDY!
The answer:
Narrowing therapy upon return of cultures and sensitivities to more targeted therapy to decrease antimicrobial exposure and contain cost.
Monitor antimicrobial therapy for appropriate use and provide interventional feedback
Discuss order changes/recommendations with infectious disease physician
Follow clinical outcomes
Provide pharmacokinetic services
Educate hospital staff on appropriate antibiotic usage
Review antibiogram regularly
Precept and mentor pharmacy students, pharmacy practice residents and infectious disease specialty residents 78 78

79. What is streamlining or de-escalation of therapy?
JEOPARDY!
What is streamlining or de-escalation of therapy?
Monitor antimicrobial therapy for appropriate use and provide interventional feedback
Discuss order changes/recommendations with infectious disease physician
Follow clinical outcomes
Provide pharmacokinetic services
Educate hospital staff on appropriate antibiotic usage
Review antibiogram regularly
Precept and mentor pharmacy students, pharmacy practice residents and infectious disease specialty residents 79 79

80. JEOPARDY!
$800 80 80

81. JEOPARDY!
The answer:
Aspect of stewardship that can result in decreased length of stay, reduced hospital costs and fewer potential complications due to prolonged IV access.
Monitor antimicrobial therapy for appropriate use and provide interventional feedback
Discuss order changes/recommendations with infectious disease physician
Follow clinical outcomes
Provide pharmacokinetic services
Educate hospital staff on appropriate antibiotic usage
Review antibiogram regularly
Precept and mentor pharmacy students, pharmacy practice residents and infectious disease specialty residents 81 81

82. What is IV to PO conversion?
JEOPARDY!
What is IV to PO conversion?
Monitor antimicrobial therapy for appropriate use and provide interventional feedback
Discuss order changes/recommendations with infectious disease physician
Follow clinical outcomes
Provide pharmacokinetic services
Educate hospital staff on appropriate antibiotic usage
Review antibiogram regularly
Precept and mentor pharmacy students, pharmacy practice residents and infectious disease specialty residents 82 82

83. JEOPARDY!
$900 83 83

84. JEOPARDY! The answer: Amount of antibiotic given that accounts for:
individual patient characteristics (age, renal function, weight)
causative organism and site of infection (endocarditis, meningitis, osteomyelitis)
and pharmacokinetic/dynamic characteristics of the drug
Monitor antimicrobial therapy for appropriate use and provide interventional feedback
Discuss order changes/recommendations with infectious disease physician
Follow clinical outcomes
Provide pharmacokinetic services
Educate hospital staff on appropriate antibiotic usage
Review antibiogram regularly
Precept and mentor pharmacy students, pharmacy practice residents and infectious disease specialty residents 84 84

85. What is dose-optimization?
JEOPARDY!
What is dose-optimization?
Monitor antimicrobial therapy for appropriate use and provide interventional feedback
Discuss order changes/recommendations with infectious disease physician
Follow clinical outcomes
Provide pharmacokinetic services
Educate hospital staff on appropriate antibiotic usage
Review antibiogram regularly
Precept and mentor pharmacy students, pharmacy practice residents and infectious disease specialty residents 85 85

86. JEOPARDY!
$1000 86 86

87. JEOPARDY! The answer: Prior Authorization
Health care information technology/ clinical decision support
Guidelines/order sets
Monitor antimicrobial therapy for appropriate use and provide interventional feedback
Discuss order changes/recommendations with infectious disease physician
Follow clinical outcomes
Provide pharmacokinetic services
Educate hospital staff on appropriate antibiotic usage
Review antibiogram regularly
Precept and mentor pharmacy students, pharmacy practice residents and infectious disease specialty residents 87 87

88. What are front-end components of antimicrobial stewardship?
JEOPARDY!
What are front-end components of antimicrobial stewardship?
Monitor antimicrobial therapy for appropriate use and provide interventional feedback
Discuss order changes/recommendations with infectious disease physician
Follow clinical outcomes
Provide pharmacokinetic services
Educate hospital staff on appropriate antibiotic usage
Review antibiogram regularly
Precept and mentor pharmacy students, pharmacy practice residents and infectious disease specialty residents 88 88

89. Conclusions
Antibiotic stewardship programs can result in increased patient safety, improved community resistance profiles, and significant cost savings.
Stewardship programs should be implemented in all health care facilities as per the 2007 IDSA guidelines. 89 89

90. Questions?
ESBL Klebsiella.
MRSA. 90 90