antimicrobial stewardship: working together to improve prescribing nyc apic chapter meeting may 16,...
TRANSCRIPT
Antimicrobial Stewardship: Working Together to Improve
Prescribing
NYC APIC Chapter Meeting
May 16, 2012
Belinda Ostrowsky, MD, MPH
ItineraryDeparture: APIC Meeting, Lenox Hill Hospital, NY Departure Time: 5/16/12 2:30pm Destination: Judicious Use of Antimicrobials Arrival Time: 5/16/12 3:30pm
I What is antimicrobial stewardship? Why is antimicrobial stewardship needed?
II Does antimicrobial stewardship work? What are specific activities of antimicrobial stewardship?What are the challenges in developing an antimicrobial stewardship program?
III What is the status of local stewardship activities?
What are some of the use, resistance and adverse event issues in my facility/our region (highlights)?
Antimicrobial Stewardship-- “Antimicrobial Management Team”
Stewardship “…the careful and responsible management of something entrusted to one's care <stewardship of our natural resources>” Merrian- Webster Online Dictionary 2009
Antimicrobial Stewardship• Healthcare institutional program to ensure
appropriate antimicrobial use– Primary goal optimize clinical outcome while
minimizing unintended consequence• Toxicity, selected pathogens (C.difficile), emergence of
resistance
– Secondary reduce healthcare costs without adversely impacting quality of care
IDSA/SHEA.CID 2007:44; 159-177.
Inappropriate Antimicrobial Use is Common
• Antimicrobials account for up to 30% of hospital pharmacy budgets
• As many as 50% of antimicrobial regimens are considered “inappropriate”
• Wrong drug, route, interval, frequency, duration
• Inappropriate use is associated with:– Increased morbidity and mortality– Increased length of stay (LOS)– Increased adverse events and antimicrobial resistance– Increased costs
Duncan. ICHE.1997;18(4):260-266.Jarvis. ICHE. 1996;17 (8):490-495Kollef M, et al. Chest 1999;115:462-74
Hecker MT. Arch Intern Med. 2003;162:972-978.
33%32%
16%
10%
0%
5%
10%
15%
20%
25%
30%
35%
REASON UNNECESSARY
Dur. Of Therapy Longer thanNeeded
Noninfectious/NonbacterialSyndrome
Treatment ofColonization/Contamination
Redundant
Hecker MT. Arch Intern Med. 2003;162:972-978.
Unnecessary AntimicrobialsWhere Do We Go Wrong?
“Unnecessary” Antimicrobial Therapy • 129 patients/2 wk period• 576 (30%) of 1941Antimicrobial Day
% U
NN
EC
ES S
AR
Y
Total Approved Antibacterials: US
0
5
10
15
20
1983-1987 1988-1992 1993-1997 1998-2002 2003-2007
Total # NewAntimicrobial Agents
IDSA. CID. 2008; (46):155-164, (Modified)
We have Bad Bugs, No New Drugs Coming!
Others are Watching (and Judging) Our Antimicrobial Use and Resistance
• Regulatory Bodies:– Centers for Medicaid and Medicare Services, Medicare
Quality Monitoring System (CMS)• Shared with the public to compare different hospitals
at www.hospitalcompare.hhs.gov– Mandatory reporting to New York State Department of
Health (NYSDOH) Healthcare Associated Infections (HAI), including C. difficile
• Consumer advocates:– Consumer Union- Force promoting state legislation for
“Mandatory Reporting of HAI”
What are the Factors that Influence Antimicrobial Prescribing/Use?
Outpatient:
•Expectation for antibiotics
Inpatient:
•Teaching facilities-prescribing by trainees
•Inpatient are more acutely ill and complex
•Pressure to keep LOS short (less watch and wait)
•First priority to prevent disaster first 24 hrs (data on delay)
•Underestimate the downside to inappropriate antimicrobials (one patient at a time and in aggregate- Medical/Family)
Avorn. Ann Int Med 2000; (33) 128-135.
Clinicians are Unlikely to Stop Therapies on Their Own
• Study short course therapy in ICU with pulmonary infiltrates
• Randomized trial using provider preference Vs. clinical pulmonary scores (Prediction Tool) Outcomes:– Antibiotics > 3 days:Provider Preference (90%) Vs. Prediction Tool (28%), p=0.001– Overall mortality, ICU LOS- no difference– Super infections, Antibiotic resistance- less in prediction tool
group– Study stopped by IRB
Singh et al. Am J Resp Crit Care Med. 2000;162:505-511
ItineraryDeparture: APIC Meeting, Lenox Hill Hospital, NY Departure Time: 5/16/12 2:30pm Destination: Judicious Use of Antimicrobials Arrival Time: 5/16/12 3:30pm
I What is antimicrobial stewardship? Why is antimicrobial stewardship needed?
II Does antimicrobial stewardship work? What are specific activities of antimicrobial stewardship?What are the challenges in developing an antimicrobial stewardship program?
III What is the status of local stewardship activities?
What are some of the use, resistance and adverse event issues in my facility/our region (highlights)?
Do Antimicrobial Stewardship Programs Work?
• Most of the data to support are from:– Inpatients– Adults– ICU
• Comprehensive programs have consistently demonstrated: – Decrease in antimicrobial use (22%-36%)– Savings of $200,000-$900,000– Success in different facility types-large academic and
smaller hospitalsMcGowen, Finland. J. Infect. Dis. 1974;134:130-165McGowan. Rev Infect Dis, 1983;5:1033-1048Monroe, Polk. Curr Opin Microbiology 2000;3:496-501Courcol et al. J. Antimicrobial Chemoth 1989;23:441-51SHEA/APIC Communication Network, Abstracted Presented at March 2008 SHEA Annual Meeting ( www.apic.org/commnetwork)
Antimicrobial Stewardship• There are National Guidelines
published by Infectious Diseases Society of America (IDSA) in 2007
• Many facilities doing elements of stewardship:
• Not under one umbrella
• Not dedicated team
• Less formal ongoing program, tracking processes or outcomes
• Guidelines, don’t tell you how to do this in your facility
IDSA and SHEA Guidelines for Developing an Institutional Program to Enhance Antimicrobial Stewardship CID 2007:44; 159-177.
Guidelines, Not one size fits all
“Tailor to your own reality (needs, size and resources) ”
Components of Antimicrobial Stewardship Programs
Core ActivitiesStewardship team-
multidisciplinary* Formulary restrictions
and preauthorization* Prospective audit with
intervention and feedback*
Supplemental StrategiesStreamlining or de-escalation
of therapy* Dose optimization* Parenteral to oral
conversation* Guideline and clinical
pathways* Education Antimicrobial order forms
Antimicrobial cycling Combination therapy *Activities with the strongest data and support by
IDSA
• IDSA and SHEA Guidelines for Developing an Institutional Program to Enhance Antimicrobial Stewardship CID 2007:44; 159-177.
Development of a Antimicrobial Stewardship Team
• Dedicated personnel• Multi-disciplinary
– Infectious Disease– Pharmacy (PharmD with Infectious Diseases
/Antimicrobial Expertise)• Support from Administration• Strong liaisons
– Pharmacy and Therapeutics Committee– Infection Control/Healthcare Epidemiology– Microbiology– Safety (others involved in Quality)– Health Information Technology
Core--Formulary Restrictions and Preauthorization with Justification
PRO • Is the most effective
method of controlling antimicrobial use
• May be useful in healthcare associated outbreaks
CON• Less clear evidence of
reducing of long term antimicrobial resistance – May just lead to shifts in use
and resistance
• The effectiveness depends on who makes the recommendations
• Mainly effects initial regimen– Less control over length of use
• Prescribers have less control (“antibiotic police”)
“FRONT END”
John, Fishman. CID. 1997;24:471-485Pear et al. Ann Intern Med. 1994;120:272-277Bamberger et al. Arch Intern Med. 1992;152:554-557.Freidrich et al. CID. 1999;28:1270-1271
Core--Prospective Audit with Intervention and Feedback
PRO
• Has been shown to improve antimicrobials use in facilities of differing sizes
• Data that it also decreased:– C.difficile
– Cost
– Resistant gram negative infections
• Benefits in hospital where daily review not feasible
CON• Labor Intensive• Have to identify opportunities
to intervene • Can be facilitated by computer
surveillance/software
“BACK END”
Solomon et al Arch Intern Med.2001;16:1897-902Fraser et al. Arch Intern Med.1997;71:941-944Carling et al. ICHE. 2003;24:699-706LaRocco. CID. 2003; 37:742-743
How Can ICPs Help?• It all the way you look at things--- Q: How do we get antibiotic resistance/C. difficile/HAIs? A: Infection control breeches, environmental cleaning
issues, transferred in, over use of antibiotics - some combo of all of these things
• Work together• Help with surveillance• Share data • Many places- share MD support • Share and complement policies
Elements of CDI Control Plans
Multi-pronged (including):
Tiered depending on burden of disease
Multidisciplinary Approach– Surveillance– Improved microbiological
diagnosis– Infection control
• Contact precautions, room placement, signage
• Hand hygiene
Adapted from APIC, Guide to the elimination of C. difficile in Healthcare Settings, 2008
Elements of CDI Control Plans (cont.)
– Environmental controls (protocols/monitoring cleaning)
– Evidence based treatment/management CDI cases
– Antimicrobial stewardship– Education of patients, families and healthcare
workers– Administrative Support
How Can You (Nurses/Non prescriber HCWs) Help?• Our partners in underscoring the importance of judicious
antibiotic use to clinicians (especially housestaff) for our patients’ safety– Nursing leadership you set the tone– Help remind clinicians about antibiotic approvals and
consultation– Encourage clinicians to reassess the needs for
antibiotics (stop, shorter courses, deescalating- narrower/oral )
– Help patients and families regarding antibiotics• Taking abx, goals of care/appropriateness of abx
(futility)
How Can You (Nurses/Other HCWs) Help?
• Help with collecting testing/cultures that will help with diagnosis (e.g., sputum, stool for C. difficile) – Appropriateness/ Timing
• Encourage good infection control/ environmental cleaning to complement antibiotic stewardship– Comply isolation/precautions, maintenance of devices– Assure environmental cleaning
• If you see something…. say something
Antibiotic “Stewardess”--Not that Far off Stewardess• Security and boarding to start your
course
• Passport
• Sees the world at 35,000 ft
• Your safety is their priority
• Recent airplane crash in NY– “miracle” vs. flight crew attributed to careful systems in place and exercise by a skilled team
Antimicrobial Stewardship• Approval for restricted
antibiotics to start antibiotic course
• Antibiograms is a passport to our local microbiology
• See the hospital’s use and resistance in aggregate (“35,000 ft” vs. just one patient at a time)
• Your patient’s safety and outcome is our priority
• Developing systems using a
specialized team to promote antibiotic use
ItineraryDeparture: APIC Meeting, Lenox Hill Hospital, NY Departure Time: 5/16/12 2:30pm Destination: Judicious Use of Antimicrobials Arrival Time: 5/16/12 3:30pm
I What is antimicrobial stewardship? Why is antimicrobial stewardship needed?
II Does antimicrobial stewardship work? What are specific activities of antimicrobial stewardship?What are the challenges in developing an antimicrobial stewardship program?
III What is the status of local stewardship activities?
What are some of the use, resistance and adverse event issues in my facility/our region (highlights)?
What’s the status of stewardship programs?
• Surveys Take a Pulse on Stewardship Activities:– Network of infection control/healthcare epidemiologist and
antibiotic resistance activities in 2007: 41% of facilities had a formal antimicrobial stewardship program
– IDSA EIN Fall 2009: 54% with stewardship programs– New York City/tri-state area- Greater N.Y. Hospital
Association (GNYHA) 40 facilities in a C. difficile collaborative:16 stewardship, most < 2 years old
• May be over estimates- how define stewardship program• There are programs U.S./international are
groundbreakers• Pharmacy community ahead
1 B .Ostrowsky et al, SHEA, Poster presentation Abstract No. 305, April 2007, Baltimore MD.
2. IDSA, EIN network, management of Inpatient Antimicrobial Use, http://www.int-med.uiowa.edu/research/ein/FinalReport_ASP.pdf
3. Internal GYNHA/UHF C. difficile collaborative data
Local Use, Resistance and Adverse Events
An Emergency Can Yield Future Opportunities
H1N1-Influenza Activities: • ASP (with IC) lead in response:
– Algorithms (N.Y. earlier activity)– Dissemination of quickly changing information/recommendation
Outcomes:• Screened > 3000+ calls (release to > 1000 patients)• 4000 webpage hits (3 weeks)/many updates• Byproduct was relationship “goodwill” with ER• Visibility (important to brand program)• Helped with future ASP interventions
Tamiflu TestingHCW Exposures
Contacts
Infection Control
Worried well
Vaccination
PneumoniaImportance:
– Common diagnosis/large volume of antibiotics– CMS Measures (external review)– Many prescriber involved [including Emergency Room(ER)]
Intervention (Compliance Initial Regimen1):– Multidisciplinary Team (ASP, Quality and ER)– Guidelines/algorithms– Restriction issues (novel tracking- Pyxis machine)– Audits/feedback – Education
Outcomes: Improved from 65% (3rd quarter 2008) to 94% (2nd quarter 2010, p=0.01)2
1. Initial regimen for community acquired pneumonia (CAP) by CMS measures2. Worked at 2 facilities- very different providers- sustained
• Hypervirulent epidemic strain of CDI (B1/NAP1)– Implicated in outbreaks throughout the US, Canada and
Europe
– Now seen in at least 40 US states (10/08)
– Exhibits: • Greater toxin production
• Greater antimicrobial resistance
Compared to the current non-B1/NAP1 strains and the uncommon historic B1/NAP1 strain
Increased Severity of CDI
McDonald LC, et al. NEJM. 2005;353 (23):2433-2441http://www.cdc.gov/ncidod/dhqp/id_Cdiff_data.html
C. Difficile (CDI)
• CDI is associated with:– Increased length of stay 2.6-4.5 days– Attributable costs for inpatient care >$2500-3500 per episode
(excluding surgery)– In U.S. estimates > $3.2 Billion annually– Attributed mortality rate 6.9% at 30 days and 16.7% at one year
• Visible/tangible outcome for physicians, patients and families
• Now mandatory publically reported HAI to NYSDOH
•Dubberke et al. CID. 2008; 46(4):497-504.
• Redelings et al. EID. 2007; 139(9): 1417-1419.
•Kenneally et al. Chest ; 2007;132(2);418-424
•McDonald LC, et al. Emerg Infect Dis. 2006;12(3):409-415.
L A A B B C C D D E E E F F G G H H H L
Subtyping C. difficile Isolates at MMC Good Infection Control May Not Be Enough?
•Few same pattern, most unique patterns•Pre “formal” MMC stewardship program•“Transferred- in” or Pressure from Antimicrobial Use?
•Assessed by Multilocus Variable Number Tandem Repeat Analysis• Geographic links – same ward, same week =same letter• Courtesy of P. Riska, M.D.
Institutional Risk Assessment Approach to Selecting Stewardship Interventions
Case Control Study
Calculation of Odds Ratios for antibiotic/class
(strength of association)
Review of aggregate antibiotic use for each
class of antibiotics (attributable risk)
Target selection
(specific antibioticor class)
Study Patterns of Use
Plan Implementation of Intervention
Measure Compliance and Impact on CDI Rates
Assess need for additional interventions
Specific Questions Regarding Antibiotics Scenarios
Choice of Intervention Type(s) to Address Majority Associated with CDI cases
CDC- Take an Antibiotic Time Out
• Step 1. All antibiotic orders -- a dose, duration, and indication.
• Step 2. Make certain that microbiology cultures are collected.
• Step 3. When your culture results come back in 24-48 hours, let's take an antibiotic time-out.From CDC Expert Commentary
Three Steps to Antibiotic StewardshipArjun Srinivasan, MDhttp://www.medscape.com/viewarticle/731784
Education and Outreach• Internal
– Housestaff– 2nd and 3rd year medical students– ID division– Pharmacy– Hospitalist– Geriatrics– NICU– Nursing Leadership– Infection Control Champions– General staff (“Get Smart about
Antibiotic Week”)
• > 1000+ Montefiore/AECOM staff/trainees
• External– IDSA- poster/invited
stewardship talk– IPRO Initiative – AHRQ– GNYHA– Antimicrobial Stewardship
Certificate program- NYSCHP/IDSNY
– Grand Rounds- Beth Israel, Beekman
• > 1000+ prescribers
Other Activities (Past/ Current)
• OR and interventional cardiology area: Removal of antimicrobial washes
• Formulary/Antibiotic subcommittee- review abx• Dosing: Pip/tazo in ICU, Vancomycin (peds/adult)• NICU: Meropenem use• Work with Microbiology:Antibiograms, testing
issues (Flu, C. difficile, MRSA, MDRO GNRs)• ER/Quality: CAP (CMS), Sepsis
Acknowledgements• Stewardship Team- Yi Guo, PharmD,
Phil Chung PharmD, & Shakara Brown, MPH• Liise-anne Pirofski, M.D. and Brian Currie, M.D., MPH• MMC Hospital Administration • MMC Microbiology- Mike Levi, PhD and Phil Gianella• MMC Infection Control Staff• ID Administrative Staff at AECOM and Moses• ID Fellows• GNYHA/UHF
Questions or comments?
Contact Info:
Belinda Ostrowsky, M.D., M.P.H.
Office 718-920-7700
Our mom says, “Antibiotics--Don’t over use them or you’ll lose them!”