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October 2016 Istanbul Dutch Guideline for Antibiotic Stewardship: What is the evidence for hospital Antimicrobial Stewardship objectives? and…how to implement it in daily practice? Jeroen Schouten, MD PhD

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Page 1: Dutch Guideline for Antibiotic Stewardship: What is the ... · Dutch Guideline for Antibiotic Stewardship: ... web-based format for a national antibiotic booklet ... • 2015 Antimicrobial

October 2016

Istanbul

Dutch Guideline for Antibiotic Stewardship:

What is the evidence for hospital

Antimicrobial Stewardship objectives?

and…how to implement it in daily practice?

Jeroen Schouten, MD PhD

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Stewardship objectives

Clin Infect Dis. (2015)

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Stewardship objectives

Blood cultures

Cultures from infection site

Guideline adherence

Antibiotic plan

Renal function

IV/PO switch

De-escalation

Stop criteria

Therapeutic Drug Monitoring

Local guide available

Local vs. national guideline

List of restricted antimicrobials

Bedside consultation

Therapy compliance

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Outcomes

Clinical outcomes Adverse events

Toxicity Costs

Bacterial resistance rates

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Inclusion and exclusion criteria 14 systematic reviews

Inclusion • Hospital or long-term care facilities • Dutch, English, German, Spanish, French • Adults (≥18yr)

Exclusion • Children (<18yr) • Outpatients/GP setting • Outbreak setting • Resource-limited settings • Prophylactic and peri-operative treatment • Malaria, HIV, Mycobacterium, H. pylori

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Search Search # of records after

duplicates removed

# of full-text articles

assessed

# of studies included in

qualitative synthesis

Empirical therapy according to the guidelines 760 110 40

Take blood cultures 1921 9 0

Take cultures from site of infection 1352 14 0

De-escalation of therapy 2726 121 25

Adjustment of therapy to renal function 1087 24 5

Switch from intravenous to oral therapy 1499 112 18

Documented antibiotic plan 234 2 0

Therapeutic Drug Monitoring (TDM) 2250 64 17

Discontinuation of antibiotic therapy if

infection is not confirmed

447 19 3

Presence of a local antibiotic guide 946 4 1

Local guide in agreement with the national guidelines 295 8 0

List of restricted antbiotics 1231 140 30

Bedside consultation 684 24 7

Assessment of patients’ adherence 868 18 0

Total 16300 669 146

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Results

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Results

Guideline adherence

De-escalation

IV/PO switch

TDM

List of restricted antimicrobials

Bedside consult

Mortality

Length of stay

Adverse events

Costs

Bacterial resistance rates

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Guideline adherence - mortality

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Guideline adherence

Length of stay

↑ 4 studies ↓ 17 studies (8 sign.)

≈ 3 studies

Treatment failure

↓ 4 studies

Cost

↓ 4 studies (2 sign.)

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De-escalation - mortality

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De-escalation

Length of stay

↑ 1 study ↓ 9 studies (2 sign.)

Number of days ICU

↓ 4 studies (2 sign.)

Cost

↑ 2 studies (1 sign.)

↓ 11 studies (5 sign.)

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IV/PO switch - mortality

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IV/PO switch

Length of stay

↓ 6 studies (6 sign.)

Cure or resolution

↑ 4 studies

Cost

↓ 11 studies (3 sign.)

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TDM - Nephrotoxicity

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TDM-Nephrotoxicity

Mortality

2 studies ↓ 6 studies (2

sign.) ≈ 1 study

Length of stay

↑ 3 studies ↓ 8 studies (5 sign.)

Cost

↑ 1 study ↓ 2 studies

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Restricted antimicrobials

Mortality Length of stay

↑ 1 study ↓ 4 studies (2 sign.)

Nosocomial infection

rates

↑ 2 studies (1 sign.)

↓ 3 studies (1 sign.)

≈ 1 study

Cost

↓ 11 studies (4 sign.)

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Bedside consultation – mortality

S.aureus

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Bedside consultation

Length of stay

↑ 2 studies (1 sign.)

↓ 1 study

Deep infection

foci identified

↑ 1 study

Cost

↑ 1 study ↓ 1 study (1 sign.)

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What does this imply for your ASP?

Guideline adherence

De-escalation

IV/PO switch

TDM

List of restricted antimicrobials

Bedside consult S.aureus bacteremia

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What does this imply for your ASP?

(Blood)cultures

Antibiotic plan

Local guide available

Local vs. national guideline

Stop criteria

Renal function

Patient compliance

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Guideline committee

Coordinator: Emelie Schuts (PhD student, AMC)

Incentive: Jan Prins (AMC) & Marlies Hulscher (IQ healthcare, RadboudUMC)

NIV/VIZ: B.J. Kullberg (RadboudUMC), J.M. Prins (AMC)

NVMM: J.W. Mouton (Erasmus MC), J. Cohen Stuart (MCA), C. Verduin (Amphia)

NVZA: H. Overdiek (MC Haaglanden), P. van der Linden (Tergooi), S. Natsch (RadboudUMC)

Verenso: C. Hertogh (VUmc)

NVK: T. Wolfs (UMCU)

NVIC: J.A. Schouten (CWZ/IQ healthcare, RadboudUMC)

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National implementation

• SWAB founded in 1996 www.swab.nl

• EBM Guidelines for Clinical Infectious Diseases (CAP, UTI, …)

• Surveillance of antibiotic use and resistance: yearly publication

of Nethmap and MARAN

• SWAB ID: web-based format for a national antibiotic booklet adaptable for every hospital

• 2012 White paper Antibiotic Stewardship: implement A-team in

every hospital, controlled by Healthcare Inspectorate

• 2014 ‘Antimicrobial Stewardship Practice Guide’ for the Netherlands www.ateams.nl

• 2015 Antimicrobial Stewardship monitor

• 2016 Guideline Antibiotic Stewardship

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Local Implementation

Dewaele, Schouten, Dimopoulos ICM 2015

WHAT? HOW?

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The WHAT in antibiotic stewardship

All professional care interventions / key recommendations with evidence

that -by performing them- stewardship goals are reached

These interventions define appropriate antimicrobial use in individual ICU patients, regarding indication, choice of drug, dose, route or duration of

treatment

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The HOW in antibiotic stewardship

The HOW of antibiotic stewardship describes recommended strategies to ensure that professionals apply these professional care interventions in daily

practice

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The HOW in antibiotic stewardship

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The HOW in antibiotic stewardship

Structural interventions Restrictive interventions o prior authorisation of selected (classes of) antibiotics o restricted formulary

Persuasive interventions o education o feedback o reminders o computerized decision support

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The HOW in antibiotic stewardship

“any stewardship intervention -whether it is restrictive, persuasive or structural- can ensure that professionals appropriately use antimicrobials”

Page 40: Dutch Guideline for Antibiotic Stewardship: What is the ... · Dutch Guideline for Antibiotic Stewardship: ... web-based format for a national antibiotic booklet ... • 2015 Antimicrobial

The HOW in antibiotic stewardship

Page 41: Dutch Guideline for Antibiotic Stewardship: What is the ... · Dutch Guideline for Antibiotic Stewardship: ... web-based format for a national antibiotic booklet ... • 2015 Antimicrobial

With permission, Sarah Cosgrove, 2011

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Model for planning change

1.Define ‘good quality care’

2.Analyse current performance of this ‘good quality care’

3. Analyse barriers influencing provision (or not) of ‘good quality care’

5.Develop plan, execute, evaluate this improvement strategy

4.Develop a quality improvement strategy based on this diagnosis

Grol. BMJ 1997

Page 43: Dutch Guideline for Antibiotic Stewardship: What is the ... · Dutch Guideline for Antibiotic Stewardship: ... web-based format for a national antibiotic booklet ... • 2015 Antimicrobial

Model for planning change

1.Define ‘good quality care’

2.Analyse current performance of this ‘good quality care’

3. Analyse barriers influencing the provision (or not) of ‘good quality care’

5.Develop plan, execute, evaluate this improvement strategy

4.Develop a quality improvement strategy based on this diagnosis

Grol. BMJ 1997

DIAGNOSTIC PHASE

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The HOW in antibiotic stewardship

STEP 1 Where is your biggest problem? What is your “low hanging fruit”? - Determine what you want to change first - Perform a baseline measurement (small numbers are enough) to

materialise the problem; e.g. use PPS - You may use a set of key quality indicators

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The HOW in antibiotic stewardship

STEP 2 What are the main drivers? determinants? of poor performance - Perform a comprehensive barrier analysis (focus group, interviews) - Prioritize the most important barriers / facilitators

Page 46: Dutch Guideline for Antibiotic Stewardship: What is the ... · Dutch Guideline for Antibiotic Stewardship: ... web-based format for a national antibiotic booklet ... • 2015 Antimicrobial

Guideline factors

Individual health professional factors

Patient factors

Professional interactions

Incentives and resources

Capacity for organisational change

Social, political and legal factors

Flottorp et al. Implementation Science 2013:

57 barriers within 7 domains

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Identification of barriers

Flottorp, Implementation Science, 2013

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The HOW in antibiotic stewardship

Cabana, JAMA 1999

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Schouten, Quality and Safety in Healthcare, 2008 R resident S specialist

M microbiologist N nurse

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The HOW in antibiotic stewardship

STEP 3 Linking a barrier to an effective intervention - Based on intervention mapping - Based on literature for change theories (EPOC)

Bartolomew, Health Education Behaviour 1998, http:// EPOC.cochrane.org

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The HOW in antibiotic stewardship

Link a barrier to an effective intervention lack of knowlegde -> education routine behavior -> reminders lack of awareness -> feedback

Bartolomew, Health Education Behaviour 1998, Ivers, Cochrane Database Syst Rev , 2012

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The HOW in antibiotic stewardship

STEP 4 Tailor the intervention using behavioral change theories lack of awareness -> audit and feedback Feedback should be -delivered in written and verbal form -by a colleague or supervisor -including explicit targets and an action plan

Ivers, Cochrane Database Syst Rev , 2012

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