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Antimicrobial Stewardship Program Implementation : The Hospital and Long-Term Care

Antimicrobial Stewardship Program Implementation : The Hospital and Long-Term Care. W.I.P.E. Out Those Bugs May 1, 2014 Kavita K. Trivedi, MD Principal, Trivedi Consults, LLC Adjunct Clinical Professor of Medicine, Stanford University School of Medicine. Objectives.

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Antimicrobial Stewardship Program Implementation : The Hospital and Long-Term Care

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  1. Antimicrobial Stewardship Program Implementation: The Hospital and Long-Term Care W.I.P.E. Out Those Bugs May 1, 2014 Kavita K. Trivedi, MD Principal, Trivedi Consults, LLC Adjunct Clinical Professor of Medicine, Stanford University School of Medicine

  2. Objectives • Discuss the rationale for optimizing antimicrobial use • Describe antimicrobial stewardship program (ASP) implementation in the hospital and long-term care • Discuss examples of ASPs in both the hospital and long-term care

  3. Rationale for Antimicrobial Use Optimization • Antimicrobial resistance • Inherent • Antimicrobial exposure • Patient safety • Arrhythmias, rhabdomyolysis, nephrotoxicity, Clostridium difficile infections, death • Cost • Unnecessary use, IV vs. PO, broad-spectrum vs. pathogen-directed therapy

  4. “The time may come when penicillin can be bought by anyone in the shops. Then there is the danger that the ignorant man may easily under dose himself and, by exposing his microbes to non-lethal quantities of the drug, educate them to resist penicillin.” Nobel lecture, 1945 Sir Alexander Fleming

  5. KPC-producing CRE in the United States 2006 DC HI PR AK Patel, Rasheed, Kitchel. 2009. Clin Micro News CDC, unpublished data Courtesy of Alex Kallen, CDC

  6. Carbapenemase-producing CRE in the United States as of February 2014 DC HI PR AK http://www.cdc.gov/hai/organisms/cre/TrackingCRE.html

  7. Rationale for Antimicrobial Use Optimization • Antimicrobial resistance • Inherent • Antimicrobial exposure • Patient safety • Arrhythmias, rhabdomyolysis, nephrotoxicity, Clostridium difficile infections, death • Cost • Unnecessary use, IV vs. PO, broad-spectrum vs. pathogen-directed therapy

  8. National Injury Surveillance System (2004-2006) • ED visits for antibiotic-related adverse effects • Estimated 142,000 per year (116K-168K) • Most prescriptions for URI, COPD, Otitis media and sinusitis • 78% due to allergic reactions (PCN) • Sulfas – highest rate of serious allergic reactions • 50% overall due to Sulfas and Clindamycin • Sulfas and quinolones associated with highest rate of neurological events Shehab et al., CID 2008:47-735-43

  9. Rationale for Antimicrobial Use Optimization • Antimicrobial resistance • Inherent • Antimicrobial exposure • Patient safety • Arrhythmias, rhabdomyolysis, nephrotoxicity, Clostridium difficile infections, death • Cost • Unnecessary use, IV vs. PO, broad-spectrum vs. pathogen-directed therapy

  10. Cost of Antimicrobial-resistant Infections (ARI) *p<0.001 Roberts RR, et al. CID 2009;49: 1175-1184

  11. Antimicrobial Approvals

  12. The Pipeline is Dry Boucher HW et al. Clin Infect Dis 2009; 48:1–12 European Centre for Disease Prevention and Control/European Medicines Agency Joint Technical Report http://www.emea.europa.eu/pdfs/human/antimicrobial_resistance/EMEA-576176-2009.pdf Only 15-16 antibiotics are in development Only 8 of these have activity against key Gram negative bacteria None have activity against bacteria resistant to all current drugs

  13. 13

  14. Antimicrobial Use in the Healthcare Continuum

  15. Tranquil Gardens Nursing Home Healthcare Continuum Acute Care Facility Ambulatory Care Home Care Long Term Care 15

  16. Acute Care vs. Long-Term Care 16

  17. Resistant Organisms are Common in Long-Term Care Facilities JAGS 2004 52:2003-2009

  18. High Rates of Multidrug-Resistant Organisms in Long-Term Care • Frequent transfer from acute care hospitals • Horizontal transmission of resistant organisms • Widespread (often inappropriate) use of antimicrobials Schwartz, DN et al., J Am Geriatr Soc 2007;55:1236-1242

  19. Antibiotic Pressure from Hospital J Am Geriatr Soc 2004 52:2003-2009; Am J Epi 2003 157:40-47

  20. Horizontal Transmission • LTCF today can promote antimicrobial resistant infections and transmission to other high-risk patients • Invasive devices and procedures increased • Central lines, chronic resp therapy, feeding tubes, dialysis, IV antibiotics • Population includes more acute and subacute patients treated previously in hospitals • Staff not given appropriate education • Changing infection control provider without expertise Nicolle, LE et al. Antimicrobial Use in LTCFs, ICHE 2000; 21: 537-545.

  21. Antimicrobial Use in Long-Term Care • Antimicrobials prescribed frequently • 40% of all systemic drugs • 8% point prevalence • 50-70% likelihood resident will receive at least one course of systemic antimicrobials during one year period • Contributes to high costs Zimmer JG et al., J Am Geriatr Soc 1986;34:703-710

  22. 25-75% of systemic antimicrobial use and 60% of topical antimicrobial use in long-term care is considered inappropriate Nicolle LE, Bentley DW, Garibaldi R, Neuhaus EG, Smith PW. Antimicrobial use in long-term–care facilities. Infect Control Hosp Epidemiol 2000;21(8):537–545. 22

  23. 30% of antimicrobial use in acute care is either inappropriate or suboptimal Cosgrove, SE, SK Seo, MK Bolon, et al. Infection Control and Hospital Epidemiology , Vol. 33, No. 4, Special Topic Issue: Antimicrobial Stewardship (April 2012), pp. 374-380. 23

  24. Take Home Message Antibiotic exposures and infection control measures in the hospital influence residents’ health at LTCFs. Antibiotic exposures and infection control measures in the LTCF influence patient’s health when they are in the hospital. 24

  25. Antimicrobial Use Optimization • Widely accepted in acute care settings*: • Improve antimicrobial resistance patterns • Decrease patient toxicity • Decrease costs • Limited literature and few studies in LTCFs • Efforts are necessary** • Regional collaborations across spectrum of care continuum is ideal *SHEA/IDSA Guidelines, CID 2007 Jan;44(2):159-77 **Schwartz, DN et al., J Am Geriatr Soc 2007;55:1236-1242 Mortensen E, KK Trivedi, J Rosenberg et al., Infection Control Hosp Epi 2014;35(4):406-411.

  26. Antimicrobial Stewardship Program (ASP) • Promotes appropriate use of antimicrobials by selecting the appropriate agent, dose, duration and route of administration • Objective: • Optimize the utilization of antimicrobial agents in order to: • Minimize acquired resistance • Improve patient outcomes and toxicity • Reduce treatment costs 26

  27. ASP Implementation

  28. Differences in ASP Implementation • Many acute care hospitals have developed ASPs due to: • Increasing prevalence of HAIs coupled with decreased reimbursement and public reporting • Lack of new antimicrobials under development • LTCFs have been slower to adopt ASPs due to: • Lack of necessary personnel • Funding • Paucity of well-validated strategies specific to LTCFs Jump RLP, DM. Olds, N Seifi, et al. Infection Control and Hospital Epidemiology , Vol. 33, No. 12 (December 2012), pp. 1185-1192

  29. Infection Control Oversight Differs Acute Care Hospitals • Must meet CMS Infection Control Standards • Most are accredited by the Joint Commission • Survey every 3 years • Also subject to complaint or validation survey by State Survey Agencies (on behalf of CMS) Non-Acute Care Settings • Few are accredited by the Joint Commission or other Accrediting Organizations • Certain types must be Medicare-certified (e.g., most nursing homes, dialysis clinics, and ASCs) • Variable state requirements re licensing. Many outpatient settings operate primarily under MD license, with limited oversight 29

  30. Infection Control Infrastructure Differs Acute Care Hospitals • Infection Control Program • Hospital Epidemiologist • Full-time Infection Preventionists • Infection Control Committee Non-Acute Care Settings • ? • Staff member with or without infection control training 30

  31. Antimicrobial Movement in the Healthcare Setting Patient Evaluation Choice of Antimicrobial Prescription Ordering Dispensing Antimicrobial 31

  32. Difficulties in Patient Evaluation in Long-Term Care • Clinical diagnosis of infection is imprecise • Symptoms not expressed or misinterpreted • Hearing and cognition impairment • Comorbid medical illness may obscure infection • Febrile response may be relatively impaired • Fever without source is frequent • Limitations in resources to support clinical assessment Nicolle, LE et al. Antimicrobial Use in LTCFs, ICHE 2000; 21: 537-545.

  33. Difficulties in Patient Evaluation in Long-Term Care • Limited availability and use of laboratory and radiological testing • Leads to empiric treatment • Evidenced-based recommendations on use of antimicrobials in LTCFs are limited • Based on clinical criteria targeted for younger populations with less complex problems • Optimal treatment regimens have not been defined Nicolle, LE et al. Antimicrobial Use in LTCFs, ICHE 2000; 21: 537-545.

  34. ASP Strategies Patient Evaluation Choice of Antimicrobial Prescription Ordering Dispensing Antimicrobial • Education/Guideline • Formulary Restriction and Pre-authorization • Computer-assisted strategies • Review and Feedback • Education/Guideline • Formulary Restriction and Pre-authorization • Computer-assisted strategies • Review and Feedback 34

  35. ASP Strategy Selection • Facility dependent • Beds and acuity of care • Dedicated personnel • Funds • Pharmacy support • Electronic systems • Laboratory support 35

  36. Infection Control Department Pharmacy Microbiology Director, Information Systems Antimicrobial Stewardship Program P&T Committee Infectious Diseases Division Patient Safety Hospital Leadership 36

  37. Stewardship Hierarchy in LTCF Most Intrusive Requires most expertise, effort and expertise. Least Intrusive Requires least expertise, effort and expense Smith, PW, Van Schooneveld TC. Ann Long-Term Care. 2011;19:20-25.

  38. Criteria for Selecting Cases for ASP Review • High cost agents • Broad-spectrum agents (eg. FQs, Pip/Tazo) • Site of infection (eg. CLABSI) • Resistance profiles (eg. MDROs, MRSA) • High risk of adverse effects (eg. Amphotericin) • Novel agents • Syndromic approach (eg. asymptomatic bacteriuria) • High use agents (facility dependent) • Double coverage of organisms (eg. anaerobes) 38

  39. Syndromic Approach • Useful in LTCFs to identify problem area and focus interventions: • Asymptomatic bacteriuria: positive urine cultures in absence of clinical signs/symptoms • Treatment indicated in pregnancy and after GU tract manipulation only • Multiple treatments often given in elderly • RCTs have shown no benefit • Does not decrease occurrence of symptomatic infection, chronic symptoms or alter mortality • Can lead to unnecessary adverse drug effects and colonization with MDROs Nicolle, LE. Infect Dis Clin North Am 1997;11(3):647-662. Loeb, M, et al., BMJ 2006; 351:669-671.

  40. Asymptomatic Bacteriuria in Elderly 5-50% of elderly patients in LTCFs have bacteriuria Over 90% of elderly with bacteriuria have pyuria No evidence of poor clinical outcomes with high levels of pyuria Some individuals high levels of pyuria >1000 WBCs/mm3 of urine May persist for months or years

  41. Management of Asymptomatic Bacteriuria • No need to treat asymptomatic bacteriuria with or without pyuria • For elderly or institutionalized • Remove indwelling catheter – replace with straight or condom catheter • No treatment unless clinical scenario warrants • Prevention measures important

  42. Syndromic Approach • An example of a criteria for selecting cases for ASP review • Target every case of patient being treated for “asymptomatic bacteriuria” • Couple with education for clinical staff • “Low hanging fruit”

  43. Examples

  44. Hospital ASPs: Improved Antibiotic Use • Cluster randomized trial over 10 months • 6 IM teams received academic detailing regarding appropriate use of vancomycin, levofloxacin, piperacillin/tazobactam • 6 IM teams received guidelines only Camins BC et al. Infect Control Hosp Epidemiol. 2009;30:931-8.

  45. Hospital ASPs: Improved Resistance, Decreased Costs McQuillen DP, et al. CID 2008;47: 1051-1063

  46. Hospital ASPs: Optimized Patient Safety • Improved surgical prophylaxis • Intervention: Simplify drug options, standardize dosing, improve timing • All doses correct • Reduction in dosing after incision (20% to 7%) • Annual cost savings $112,000 • Improved renal dosing • Intervention: Clinical decision support system and academic detailing • Appropriate dosing of gentamicin increased from 63% to 87% • Appropriate dosing of vancomycin increased from 47% to 77% • Appropriate use of gentamicin therapeutic monitoring increased from 70% to 90% Willemsen I et al. J Hosp Infect. 2007;67:156-160. Roberts GW et al. J Am Med Inform Assoc. 2010;17:308-12.

  47. LTCFs: Education Can Work to Reduce Treatment of Asymptomatic Bacteriuria Am J Infect. Control 2008 Sep; 36 (7): 476-80.

  48. LTCFs: Education Can Work When Coupled with MD Feedback • Cluster-randomized, controlled trial of eight LTCFs • Educational intervention done twice four months apart: antibiotic guide distributions to MDs along with individualized antibiotic prescribing profiles over the previous 3 months • Decrease in nonadherent antibiotic prescriptions (OR, 0.36; 95% CI 0.18–0.73) Monette et al. J Am Geriatr Soc. 2007 Aug;55(8):1231-5.

  49. California Dept Public Health Investigation in LTCF: 2010 • Point prevalence study in LTCF with high rate of MDR Acinetobacter baumannii • Baseline colonization rate 19% • 36% colonized residents MDR (resistant to cephalosporins, FQ, aminoglycosides) • Implemented strict infection control practices • HH, cohorting, contact precautions • Enhanced environmental cleaning • Follow-up six month colonization rate remained 19% • 36% colonized residents negative 6 months previous • 71% colonized residents MDR Mortensen, E et al., Infection Control Hosp Epi 2014; 35(4):406-411; Trivedi, K et al., unpublished data

  50. CDPH: ASP in LTCF Study 2011-2012 • Goal: characterize the benefit of implementing a formal ASP in LTCF • Establish ASP in three LTCFs • Post-prescriptive review and feedback with pharmacist and ID physician • Establish feasibility and effectiveness • Specify effects of ASP on antimicrobial utilization, susceptibility patterns and rates of Clostridium difficile over time Doernberg, S et al., unpublished

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