1. How to Start an Antimicrobial Stewardship Program
In Conjunction with AzHHA’s Safe and Sound Patient Safety Initiative
Patty Gray RN, CIC & Bill Wightkin, Pharm D, R.Ph

2. Learning Objectives
After listening to the presentation, viewing Power Point slides and participating in a question and answer session, the participant will:
A. Be able to list the recommended components of an antibiotic
stewardship program
B. Be able to detect antibiotic use improvement opportunities
from the analysis of utilization data
C. Be able to explain the barriers for successful
implementation of such a program

3. Presentation Outline
I. Why Develop an Antimicrobial Stewardship Program?
A. Infection control nurse’s perspective
B. Hospital pharmacist’s perspective
II. Recommended Components of a Program
III. Scottsdale Healthcare’s Program
A. Short history
B. Committee membership and leadership
C. Goals of the committee
D. Activities-to-date
E. Results so far
F. Opportunities for improvement
G. Next steps
IV. Audience questions and answers

4. Why Develop an Antimicrobial Stewardship Program
From an Infection Preventionist Perspective:
Track and Reduce antimicrobial resistance
Encourage appropriate treatment patterns ~ The right antibiotic, for the right duration
Develop a collaborative practice between MDs/LIPs, Pharmacy, Laboratorians and Infection Preventionists’ with best patient outcome in mind
Education Catalyst

5. Why Develop an Antimicrobial Stewardship Program?
Hospital Pharmacist’s Perspective:
Allows needed FOCUS on a drug class
Need to assure appropriate medication management and safety
Assist with educational efforts
Assist with formulary standardization
Control costs

6. Antimicrobial Purchases
Yearly Expense
Daptomycin
$696,000
Pip/Tazo
$585,000
Zyvox
$444,000
Primaxin
$415,000
Caspofungin
$400,000
Levofloxacin
$338,000
Invanz
$335,000
Tygacil
$284,000
Expense of Top 100 Drugs:
$17.5 million/yr
Antimicrobials = $5 million/yr
29%

7. Recommended Components of an Antimicrobial Stewardship Program
Foundation = 2 core, proactive strategies
Prospective audit with intervention and feedback
Formulary restriction and preauthorization

8. Other Recommended Components of an Antimicrobial Stewardship Program
Standardized order sets and clinical pathways
(foster evidence-based prescribing)
Antimicrobial order forms
De-escalation of therapy (Review C&S results; on-going review of therapy)
Dose optimization (right dose for site of infection;
renal dose adjustment)
IV to oral dose conversion

9. Scottsdale Healthcare’s Program: History
Evolution from an Antibiotic Subcommittee of the P&T Committee
Perception of an Antibiotic Restriction and Control Approach
Acknowledgement of Hospital and Community considerations
Need for Administrative and Board Support
Mission Development ~ Educational/Cooperative Focus~ Stewardship
University of Kentucky Program- Dr. R. Rapp
New Hospital with need for guidelines upon opening of facility

10. SHC Program~ Committee Membership and Leadership
Medical Staff- Active participation is critical to success
Includes Chief Medical Officer support, ID , Hospitalists, Intensivists, Pulmonary, ED, Community MDs and others as willing
Pharmacy- Coordinates the efforts of the team, guideline development, education and tracking reports
Infection Prevention & Control- Prevention Strategies, hand hygiene, precautions, medical staff-nursing laison
Microbiology- Data trends, special testing expertise
Quality & Organizational Development- Performance Improvement guidance; meeting guidance

11. Goals of Committee
Assist providers in appropriate use of antimicrobial therapy with improved patient outcomes
Slow the development of antimicrobial resistance
Develop evidence- based appropriate use guidelines
Educate providers and staff regarding guidelines
Track resistance patterns and report back to medical and hospital staff
Report committee progress and outcomes to P&T, and Executive Committees

12. Activities to Date Developed guidelines for 4 antimicrobials
Day 7 of therapy reminder to chart
Day 10 of therapy phone call from pharmacy ID resident
Drug utilization evaluation (DUE)

14. Results so far (2 months of data)
Drug
% of patients with an
Infectious Disease Physician Consultation
Criteria
Non-Conformance
Rate
Caspofungin
100% (30 patients)
23% (no de-escalation to another agent with
Candida albicans)
Daptomycin
93% (41 patients)
24% (no trial of vancomycin for skin infections)
Linezolid
82% (33 patients)
64%
Tigecycline
79% (34 patients)
68%

15. Opportunities for Improvement
DUE reveals significant non-conformance to adopted guidelines
Are guidelines appropriate?
It does not appear that ID physicians are sufficiently
engaged in the stewardship activities
Stewardship Foundation = 2 core, proactive strategies
Is our process ROBUST (interventions after 7-10 days)??

16. Barriers & Opportunities for Improvement
Cultural Perceptions- Medicine’s Heirarchy
Integration of Team Approach and Evidenced Based Practice into culture
Continued Involvement of Hospitalists & Community MDs
Infectious Disease MDs support, agreement & use of guidelines
Turnover of Pharmacy Leadership
Ongoing Administrative Support

17. Next Steps Re-evaluate physician leadership
Formulary evaluation: caspofungin vs. micafungin vs. anidulafungin
Transition from faculty ID pharmacist leadership to
SHC pharmacy clinical staff
4. Explore expansion of pharmacist clinical duties to include
antimicrobial stewardship responsibilities
5. Improvement of the 2 core proactive strategies

18. Next Steps
ASK WHY…...determine and address prime causative factors that have resulted in:
Antibiotic overuse
Sub-optimal antibiotic selection
Too long duration of therapy
Lack of de-escalation to more appropriate agents
Slow switch to oral therapy
Marketing pressure?
Education-Training-Competency?
Workload issues with poor attention to detail?
Insufficient pharmacy involvement?

20. References
Dellit TH, Owens RC, McGowan JE, et al. Infectious Diseases Society of America
and the Society for Healthcare Epidemiology of America guidelines for
developing an institutional program to enhance antimicrobial stewardship.
Clin Infect Dis. 44 (1): , 2007.
McQuillen DP, Petrak RM, Wasserman RB, et al. The value of infectious disease specialists: Non-patient care activities. Clin Infect Dis. 47: , 2008.
Spellberg B, Guidos R, Gilbert D, et al. The epidemic of antibiotic-resistant
infections: A call to action for the medical community from the Infectious
Diseases Society of America. Clin Infect Dis. 46 (2): , 2008.

21. Antimicrobial Stewardship
QUESTIONS?