Antimicrobial Stewardship Programat SCGH

Jason SeetID/Critical Care Pharmacist

Sir Charles Gairdner Hospital

Background All drugs have adverse effects Antibiotics have an ‘additional effect’

Known as ‘collateral damage’ Refers to the impact of the antibiotic on

the colonising bacterial flora Selection of antibiotic resistant

microorganisms Patient becomes colonised with resistant

organisms

The dilemma... Antibiotics are one of the most important

discoveries in modern medicine.. However, inappropriate use of

antimicrobials may lead to ‘collateral damage’

On the other hand.. Severe restriction of antibiotics (inadequate

therapy) in seriously ill patients is associated with increased mortality

??.. Solution

The role of the Antibiotic Stewardship Program is to strike a balance between appropriately

treating the patient and avoiding the selection of antibiotic resistant organisms

Role of antimicrobial stewardship programs (ASP) Aim to

Optimise antimicrobial therapy (PRIORITY) Improve overall patient outcome Minimise adverse events Decrease the risk of development of

antimicrobial resistance Reduce treatment related costs

How is this achieved?To optimise therapy

Improve selection/choice of antimicrobial – refer to microorganism, susceptibilities, resistance patterns, antibiotic spectrum

Duration (eg: t1/2), overall therapy duration Dose – site of infection, drug factors (Vd, Cl,

bioavailability) Route of administration (IV vs po)

How is this achieved? Reduce antimicrobial costs

Limit overuse Narrow spectrum chosen (avoid inappropriate

use) Promote active IV to po switch Reduce hospital length of stay (minimising

infections due to resistant organisms)

Minimise adverse events TDM Dosage adjustments (individualise therapy)

NAUSP 2006-2009 data

Data demonstrating total antibiotic usage amongst hospitals inAustralia

How did SCGH fare in 2009…?

CefepimeClindamycin

CiprofloxacinAzithromycin Meropenem

Timentin/TazocinAugmentin DF

The podium of shame

Outcome of this high usage.. Implementation of an Antimicrobial

Stewardship Program (February 2010)

HAPI (Healthy Antimicrobial Prescribing Initiative) ‘ward-side’ review of restricted antimicrobial

therapy Written recommendations documented in notes

HAPI Round

Antimicrobial Committee

Site-specific guidelines and antibiograms

Electronic decision support

HAPI roundsConsists ofID Pharmacist ID Physician/Clinical Microbiologist+/- ID Registrar+/- Microbiology Registrar

Review of patients onRestricted antimicrobialsProlonged course/s of antimicrobials

HAPI roundsThe team will provide advice to the treating team in regards to most appropriate antimicrobial therapyEg Cessation of therapyChange in therapyNarrow therapy Broaden therapySwitch to oral de-escalationReferral for ID consult

Why we need AMS? Broad spectrum antimicrobials

commenced

Appropriate therapy initially

Micro results returnPathogen identifiedSusceptibility results available

Patient improves..But still on broad spectrum antimicrobials

Infection resolved.Patient still on broad spectrum antimicrobials

Patient ready for dischargeBroad spectrum IV antimicrobials changed to broad spectrum oral antimicrobials

Impact of AMS rounds

SCGH

Ongoing reduced usage

SCGH

HAPI rounds 4 x week rounds on general wards 2 x week rounds in ICU and GHDU 1 weekly round with Haematology team

Soon.. eReferral option to AMS (HAPI team) for

assistance with antimicrobial choices, de-escalation of therapy etc

Can we relax…?

Can we relax…?

How can I find out more info?http://chips.qe2.health.wa.gov.au/projects/HAPI/index.html

Contact your clinical pharmacist

Link available via DFShttp://dfsprod.hdwa.health.wa.gov.au/LoginPage.aspx

What can YOU do? Overuse/abuse of antimicrobials affects

everyone!

How can you help? Request the prescribers to document

antimicrobial indication on chart Antimicrobials warranted?

Encourage the prescriber to request ID approval for restricted antimicrobials

Question antimicrobial duration/s Encourage IV to oral switch Refer patients on prolonged antimicrobials to

the HAPI team or your clinical pharmacist