Antimicrobial Stewardship

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. 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 Proton Pump Inhibitors Asthma Drugs

21. ACT-Medication ManagementAnti-Infective Stewardship Initiative 2010 2010 Target