This presentation was presented at

Apollo International Forum on

Infection Control (AIFIC’ 2013),

Chennai

The presentation is solely meant for

Academic purpose

Antimicrobial Stewardship

Different Challenges need Different Solutions

Columbus, Ohio USA

The Ohio State University Medical Center

• James Cancer Center 165 beds bone marrow transplants & oncology

• Ross Heart Hospital 130 beds Heart and lung transplants

• The Ohio State University Hospital 850 beds solid organ transplant, General Medicine Surgery, SICU, MICU, NICU, Burn unit

Antimicrobial Resistance: A Global Problem

Antimicrobial Stewardship: A Global Solution!

MDRO are a plane ride away!

Examples: NDM-1,KPC, ESBL, Tuberculosis

Antimicrobial Stewardship

A Global Solution!

Why Stewardship? HAI’s: significant morbidity, mortality and costs

100,000 deaths annually $4.5 to 5.7 billion patient care cost

Transmission occurs most often via contaminated hands of HCW

Negative publicity for the hospital (patient safety issue)

The Ohio State Football Stadium holds 105,000 people

Stewardship: A team approach

Challenges and Barriers in India

• Lack of ID trained physicians and

pharmacists

• Lack of funding

• Open access to antibiotics

• Generics

What are USA patient’s reading?

Ref: Wall Street Journal January 2013

What works What Doesn’t

Social competence

Do you enjoy interacting with others?

Socially challenged

Prefer to work alone

Needs to be liked by everyone

Avoids conflict at all costs

Technical competence

Are you an ID expert?

Can you lead a team?

Technically challenged

Hopes others on the team will do the work

Implementation of ASP should be conceived as a

process of cultural and system change for the hospital

If the team does not possess the change management

competence, it may be necessary to involve external

experts

Excited to change

Frustrated at the thought of change

What Works What Doesn’t Work

Organizational Capacity for Change

• Trustworthy leadership Do MDs know/trust the steward?

• Capable Champions Are efforts led by people with interpersonal communication and leadership skills?

• Accountability Does ASP have a clearly defined role and responsibility? Are there consequences for non-compliance?

• Involved Management Do they support the program and connect with leadership? Judge WQ et al. Journal of Business Research. 2005;58:893-901.

What works: Define the Stewardship activities

What activity will be performed… Examples

IV to PO

Kinetic dosing of antibiotics

Authorization of restricted antibiotics

Feedback for targeted antibiotics

By what personnel…. Dedicated pharmacist

Physician

Residents or students

With what frequency… Mon-Friday

7 days a week

24/7

With what authority… Protocols for IV to PO

Kinetic dosing protocol

Communication of recommendation via

chart

What works? Pick the low hanging fruit

IV to PO conversion

Double anaerobic therapy

Broad spectrum antibiotics > 3 day and proton pump inhibitors

(increase risk of C. difficile)

Vancomycin > 3 days and no MRSA

Positive blood culture and no antibiotics

Thrombocytopenia and linezolid

Ref: Goff DA. et al . Clin Inf Dis 2012 55(4):587-92

Insist on Infection Prevention Strategies

• Provide education to patients and

family members

• Provide/post medical staff

scorecards with frequency and

trends of MDRO Do physicians know the top 5 organisms in their hospitals?

• Do physicians know the rate of ESBLs, C difficile, MRSA?

Challenge

How can stewardship

control the spread of

MDRO in your hospital?

(X Represents VRE Culture Positive Sites AFTER Cleaning)

Hayden M, The Risk of Hand and Glove Contamination after Contact with a

VRE (+) Patient Environment. ICAAC, 2001, Chicago, IL.

USA and India working together to

improve hand hygiene

• Method: 17 bed ICU used remote video

auditing with feedback

• Auditors in India viewed live video of HCW

in a US hospital performing hand hygiene

• Each observation was assigned pass/fail

Ref: Armellino D et al. 2012 Clin Inf Dis 54(1) 1-7.

Results 60,542 observations

• Pre-feedback hand hygiene rates 6.5% (3.5%-9.8%) by remote 24/7 observation

• Post-feedback

30.8% the first few weeks

87.9% with light-emitting diode boards

Message Posted on LED boards

Black Light Marker • Fluorescent marker

– An invisible gel that glows under blacklight

– Applied to surfaces in over 40 US hospitals

– An inert, safe, and unreactive substance

Without black light

Ref: Carling PC. Clin Infect Dis 2006;42(3):385

Challenge How can you control the spread of MDRO in your hospital?

Solutions 1. Novel technology

2. Empower patients* (only 14% of patients feel comfortable asking their MD/RN to wash their hands)

Ref *2012 ICHE Ottum 33(12)1282-4,

3. Identify patient s at high risk for MDRO Ref: Han et al. 2012 ICHE;33(12) 1242-5

4. Chlorhexidine bathing 70% decline in CDI with daily bathing

Ref: Rupp et al. 2012 ICHE;33(11):1094-1100

Stewardship in Limited

Resource Hospitals around

the world

Stewardship in S. Africa

Challenges: 3 ID physicians for all of S Africa, lack of funding,

pharmacist are not ID trained, some public hospitals do not have sinks

Stewardship and S. Africa • Implemented Feb 2012

• Dedicated “champions” across S.

Africa (physicians, infection control practitioners,

pharmacists, microbiologists)

• Collaboration between public and

private hospitals, administration and

government

Stewardship and S. Africa • Projects

iv to oral

de-escalation

implementing antibiograms

• Education

12 enrolled in on-line certification program in US

• email communication

• Conference calls, Facetime, Skype

• Integrate “apps” to educate providers

• Twitter

Outcomes of Stewardship • S. Africa

successful conversion of IV to PO

therapeutic vancomycin levels

develop antibiogram

• Dubai

ICU improve “Hang-time” of antimicrobials

• Serbia developed a “team” to identify how to utilize

micro data to guide empiric use of antibiotics

Antimicrobial Stewardship Management of

Infections : Beyond the Costs of Antimicrobials

Ref: Goff D. et al. Inf Dis Special Ed. 2012 15:35-46

Antimicrobial Stewardship Management of

Infections : Beyond the Costs of Antimicrobials

Ref: Goff D. et al. Inf Dis Special Ed. 2012 15:35-46

Challenge

How does stewardship

impact patient care?

Clinical Outcome Measures Can you show improvement in clinical outcomes?

• Reduced LOS Bauer K., Goff D. Clin Inf Dis 2010; 51(9):1074–1080

Fishman N. Am J Med 2006;119 (6 suppl 1) S53-S61

Gentry CA AM J Health Syst Pharm 2000;57(3) 268-74.

• Better patient outcome Bauer K., Goff D. Clin Inf Dis 2010; 51(9):1074–1080

Fishman N. Am J Med 2006;119 (6 suppl 1) S53-S61

White A. et al Clin Inf Dis 1997;25:230-9.

• Decreased inappropriate use Gandhi T. Crit Care Med 2010;38(8 suppl) S315-323

Apisarnthanarak A. Clin Inf Dis 2006;42(6) 768-775

What works: Technology and Education

• ASP certification program in USA MAD-ID Making a Difference Infectious Diseases international online program

S. Africa, Singapore, Canada, Saudi Arabia, Australia

http://mad-id.org

• Free apps from the Apple store Idpodcasts Weekly podcasts on ID topics

• Free webinars and handouts

ASHP American Society of Health Systems Pharmacists

www.LeadStewardship.org

• http://www.cdc.gov/getsmart/specific-groups/hcp/index.html

free handouts, brochures, powerpoint slides on ASP

So what can you do?

• Start now

• Collaborate

• Identify key leaders to develop guidelines

(based on national guidelines, tailored to your institution)

• Consequences for non compliance?

• Educate (telemedicine programs) School of Telemedicine and

• Biomedical Informatics, Sanjay Gandhi Postgraduate Institute of Medical Sciences

Lucknow, India.

• Patient’s lives depend on effective stewardship

Stewardship