Antimicrobial Stewardship

The Problem Antibiotic resistance is a worldwide problem Antibiotics are among the most commonly prescribed drugs used in human medicine Up to 50% of antibiotics prescribed for people are unnecessary or inappropriate Misuse of antibiotics leads to the emergence and spread of antibiotic resistant organisms (e.g., methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci, etc.) Healthcare-associated infections (e.g., Clostridium difficile, etc.)

“…the thoughtless person playing with penicillin treatment is morally responsible for the death of the man who finally succumbs to infection with the penicillin-resistant organism.” Alexander Fleming

National Action Plan to Combat Antibiotic Resistance The Centers for Disease Control and Prevention (CDC) advised acute care hospitals to implement antibiotic stewardship programs (ASPs) The Joint Commission (TJC) implemented antimicrobial stewardship standard MM.09.01.01 effective date January 1, 2017 The Centers for Medicare & Medicaid Services’ (CMS) intends to require all acute care hospitals and long-term care facilities to incorporate an ASP as a mandatory Condition of Participation

Antibiotic Stewardship Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials including antibiotics, improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms. Utilizes informatics, data collection, personnel, and policy/procedures to promote optimal selection, dosing, and duration of therapy for antimicrobial agents throughout the course of their use

ASP Core Elements Leadership Commitment: Dedicating necessary human, financial, and IT resources Accountability: Single physician leader responsible for outcomes Drug Expertise: Single pharmacist leader responsible for outcomes Action: Implementing specific, proven interventions Tracking: Monitoring antibiotic prescribing/resistance patterns Reporting: Informing key stakeholders of progress regarding antibiotic use & resistance Education: Updates on resistance & optimal prescribing

ASP Goals improve patient outcomes; slow the emergence of resistance; prevent the spread of infections; limit toxicity associated with antimicrobials including secondary infections (eg, Clostridium difficile); contain costs.

Optimal Antimicrobial Use All prescribers at ETMC Tyler are expected to adhere to the following principles when prescribing antimicrobial therapy: Empiric therapy initiate promptly after collection of appropriate specimens (whenever appropriate and possible); target likely pathogen and source (anatomic site of infection); consider possible antimicrobial resistance based on recent antimicrobial exposure and local resistance patterns;

Optimal Antimicrobial Use Empiric therapy select the narrowest spectrum possible for achieving the intended effect; determine the appropriate dose, route and frequency of therapy; Tailoring therapy review microbiology results and broaden or narrow therapy as appropriate; convert intravenous therapy to oral as soon as possible and clinically indicated. Duration of therapy use shortest effective duration of therapy.

ETMC Antimicrobial Stewardship ETMC established an ASP in 2007 ASP core membership: Infectious Diseases physician clinical pharmacists

ETMC Antimicrobial Stewardship ASP activities Prospective audit of all inpatient antimicrobial use twice weekly IV to oral conversion of therapy Dose adjustment/optimization Detection and prevention of antibiotic-related drug-drug interactions Improve adherence to guidelines Therapeutic drug monitoring

ETMC Antimicrobial Stewardship Tracking and Reporting Medication use evaluations/antibiotic audits to assess quality of antibiotic use Days of antibiotic therapy Detecting/monitoring trends in antimicrobial resistance

Bacteria vs Antibiotics Inappropriate use of antibiotics contributes to emergence and spread of antibiotic resistant organisms and health-care associated infections. Antimicrobial stewardship is vital for preserving existing antibiotics and improving patient outcomes while minimizing unintended consequences. Antibiotic prescribing should be prudent, thoughtful and rational.

It was on a short-cut through the hospital kitchens that Albert was first approached by a member of the Antibiotic Resistance.