1. Antimicrobial Stewardship St. Mary’s Hospital Infection Control Committee

2. What is Antimicrobial Stewardship An interdisciplinary team dedicated to practices that improve appropriate selection, dosing, route, and duration of antimicrobial therapy The ultimate goal of antimicrobial stewardship is to improve patient care and health care outcomes

3. Antimicrobial Stewardship Team Infectious Disease Physician Clinical Pharmacist Clinical microbiologist Information System Specialist Infection control professional Hospital epidemiologist Leadership support

4. Elements of an Antimicrobial Stewardship Team A comprehensive program will include: – Active monitoring of resistance – Fostering of appropriate antimicrobial use – Collaboration with an effective infection control program to minimize secondary spread of resistance is considered optimal

5. Elements of an Antimicrobial Stewardship Program Prospective audit with intervention and feedback Formulary restriction and preauthorization Guidelines and clinical pathways Antimicrobial cycling Antimicrobial Order Forms Monitoring of progress and outcome measures Education De-escalation of therapy Dose optimization Conversion from parenteral to oral Computer Surveillance/Decision Support Microbiology Laboratory

6. Prospective audit,intervention,and feedback Have the clinical pharmacist on the floor making recommendations about appropriate antibiotic, route, length of therapy Probiotic Protocol to prevent C. Diff Focus on one floor for recommendations Up to a 37% reduction in the number of days of inappropriate antibiotic use.Approx. $400.00 cost savings per patient While assessing patients for probiotics look at de- escalating of antibiotics Decrease rate of C. Diff

7. Formulary restriction and preauthorization requirements for specific agents Control of certain antibiotic use through Pharmacy and Therapeutics Committee can be very effective Control of Cleocin use has led to prompt cessation of nosocomial outbreak of C. Diff Restriction of Vancomycin and third generation cephalosporins in response to VRE has demonstrated mixed results

8. Education Conference Presentations Student teaching E-mail alerts Provision of written guidelines Peri-operative area order forms Share results of audits

9. Guidelines and Clinical Pathways Implementation of guidelines incorporating local microbiology and resistance patterns Balance antibiotics in HAP and VAP patients Use algorithms incorporating the clinical pulmonary infection score Leads to decreased duration of therapy,decreased VAP recurrence, decrease of multi- drug resistance patterns

10. Antimicrobial Cycling Slows spread of resistance Most popular is Gentamicin to Amikacin Ceftazadime for Ciprofloxacin lead to a decreased incidence of VAP

11. Antimicrobial Order Forms Use of Peri-operative prophylactic order forms with automatic stop at 2 days (SCIP Guidelines) Pneumonia Order set (Pneumonia core measures) with 6 different pneumonia indications and drugs Order forms facilitate implementation of practice guidelines

12. Streamlining or De-Escalation of therapy Continuing excessive broad therapy contributes to the selection of antimicrobial resistant pathogens When culture results become available we can streamline or de-escalate antimicrobial therapy to more targeted therapy that decreases antimicrobial exposure and contains cost This can also lead to avoidance of redundant inpatient antibiotic- days

13. Dose Optimization Dosing that accounts for individual patient characteristics (age,weight,renal function) Site of infection Pharmacokinetics - Vancomycin and aminoglycosides Optimize antimicrobial pharmacodynamics of the drugs B-lactams and fluoroquinolones

14. Conversion from parenteral to oral therapy Having a systematic plan for switching from parenteral to oral treatment may have an added benefit of aiding in early hospital discharge planning Development of clinical criteria and guidelines allowing conversion can facilitate implementation.

15. Computer Surveillance / Microbiology Add cost codes to antimicrobial susceptibility data Antimicrobial report to pharmacy Vancomycin dosing/utilization sheet Review antimicrobial errors Leap frog to CPOE Actively involved in resistance surveillance Update antibiogram annually Make easily accessible to physicians

16. St.Mary’s Antibiotic Stewardship Efforts to Date Probiotic Protocol Antibiogram on line Pneumonia Order sets Pharmacokinetics Peri-op Area Guidelines IV to PO conversion Culture results from lab Pharmacy/IS generated pneumonia vaccine program

17. What does our future hold for Antibiotic Stewardship Assign antibiotic rounds to new pharmacy school professor ( de-escalating and streamlining) Follow culture results from lab Approve IV to PO conversion automatic by pharmacist Finish 6 month Probiotic study Work on Vancomycin Order form

18. Antibiotic Stewardship 2013

19. Change Dose Change Antibiotic IV to PO conversion Discontinue Therapy Add an antibiotic Renal dosing StreamlineOther:Probiotic Accepted1 1021281152 8 Not accepted 5 631 Total11527312152 8 Documentation of Interventions by type MONTH : SEPTEMBER 2013 Total Antibiotic Interventions:100 Percent Accepted: 85% April Ecker and Gin Fleming (Antibiotic Pharmacist)

20. C.H.E. Act Initiatives Thru September 2013 Anti-infectives (Antibiotics) Anticoagulants Asthma Drugs Proton Pump Inhibitors

21. ACT-Medication Management Anti-Infective Stewardship Initiative 2010 2010 Target