1. Antimicrobial Stewardship in Long Term Care Shira Doron, MD Assistant Professor of Medicine Associate Hospital Epidemiologist Tufts Medical Center

2. What is Antimicrobial Stewardship? Antimicrobial stewardship involves the optimal selection, dose and duration of an antibiotic resulting in the cure or prevention of infection with minimal unintended consequences to the patient including emergence of resistance, adverse drug events, and unnecessary costs. Dellit TH, et al. CID 2007;44:159-77, Hand K, et al. Hospital Pharmacist 2004;11:459-64 Paskovaty A, et al IJAA 2005;25:1-10 Ultimate goal is improved patient care and healthcare outcomes

3. Infectious Diseases Expert Resources Infectious Diseases Specialists Antimicrobial Stewardship Antimicrobial Stewardship Infection Control Professionals Information Technology Specialists Clinical Pharmacists Quality and Patient Safety Staff Infectious Diseases Trained Pharmacists Clinical Microbiologists Hospitalist or other clinician

4. Antimicrobial Stewardship Strategies Prospective audit with intervention and feedback “Front end”: Antimicrobial restriction and preauthorization “Back end”: Prospective audits Formulary restriction Education, guidelines, clinical pathways Dose optimization via PK-PD De-escalation/Streamlining Antimicrobial order forms/order sets if CPOE IV-PO switch Computerized decision support Dellit TH, et al. CID 2007;44:159-77 Hand K, et al Hospital Pharmacist 2004;11:459-64 Paskovaty A, et al IJAA 2005;25:1-10

8. Stewardship in Long Term Acute Care

9. Issues specific to LTACHs ID resources – May not have full time ID physician – Unlikely to have an ID pharmacist Moonlighters – Tend to practice according to their “home” institution The antibiogram – Combined resistance patterns of all of the referring hospitals The formulary – Must be able to accommodate the referred patient

10. New England Sinai Hospital

11. The program Worked with leadership, ID consultant, IP, Pharmacy director End date and indication required by pharmacy for all antimicrobials List of the “great eight” antimicrobials 2 ID physicians, off-site, M-F Log on and generate report: patients on antimicrobials at least 7 days Review electronic medical records Recommendations made by email Clinical pathways

12. Results: Types of Infections April 2011 – July 2012, n=530 12

13. Results: Types of Recommendations April 2011-July 2012 13

14. Results: Types of Antimicrobials, April 2011 – July 2012 14

15. Results: NE Sinai Antimicrobial Usage Medications DDD/1000 patient days Year Prior DDD/1000 patient days Year After Fluoroquinolones 3.76.1 3 rd and 4 th generation Cephalosporins 18.921.6 Carbapenems 30.931.3 Linezolid (PO and IV) 20.313.7 PO Vancomycin 49.118.4 PO Metronidazole 34.424.9 15

16. Stewardship in Long Term Care The challenges: – Staffing – Funding – Buy-in – Time

17. Simple things you can do Pick the low-hanging fruit

18. Guidelines/clinical pathways/order forms

23. Education

25. Probiotics “Living microorganisms which upon ingestion in certain numbers exert health benefits beyond inherent general nutrition”

26. Can probiotics help prevent C. diff from developing in patients taking antibiotics? Cochrane systematic review 2013: –1871 studies, 31 met criteria to be included, 4492 subjects –Probiotics reduced risk of C. diff associated diarrhea by 64% (2% in probiotic group versus 5.5% in placebo/no treatment group) Goldenberg et al. Cochrane Database of Systematic Reviews 2013, Issue 5.

27. Can probiotics help prevent C. diff? Authors’ conclusions: “Based on this systematic review andmeta-analysis of 23 randomized controlled trials including 4213 patients,moderate quality evidence suggests that probiotics are both safe and effective for preventing Clostridium difficile-associated diarrhea.”

28. Can probiotics help prevent C. diff? Caveat: each probiotic strain behaves differently. One cannot extrapolate results from a study using one strain to the efficacy of another.

29. Most common US probiotics: –Lactobacillus acidophilus –Lactobacillus GG (Culturelle ® ) –Lactobacillus reuteri –Bifidobacterium (various) –Saccharomyces boulardii (Florastor ® ) –Combination products (VSL # 3 ® ) Probiotics