strategies to reduce antibiotic consumption and inadequacy ... bouza - o... · strategies to reduce...
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Strategies to reduce antibiotic
consumption and inadequacy and
the emergence of bacterial
resistance:
Strategies to reduce antibiotic
consumption and inadequacy and
the emergence of bacterial
resistance:resistance:
The microbiologist role
resistance:
The microbiologist role
Emilio Bouza
Porto. March. 2010
Emilio Bouza
Porto. March. 2010
Antimicrobial stewardshipAntimicrobial stewardship
Is an ongoing effort by a health care institution to optimize antimicrobial use among hospitalized patients in order to:
improve patient outcomes
Is an ongoing effort by a health care institution to optimize antimicrobial use among hospitalized patients in order to:
improve patient outcomesimprove patient outcomesensure cost-effective therapyreduce adverse sequelae of
antimicrobial use
improve patient outcomesensure cost-effective therapyreduce adverse sequelae of
antimicrobial use
MacDougall C. Clin.Microb.Rev. 2005
Antimicrobial stewardshipAntimicrobial stewardship
Antibiotic policies
Antibiotic management programs
Antibiotic control programs
Antimicrobial stewardshipAntimicrobial stewardship
A lot of opinion.
Not much scientific data
Scarce practical information on “how
to do it”
IndexIndex
Team composition
Team operation
Data provided
Team composition
Team operation
Data providedData provided
Educative measures
Active interventions
Outbreaks management
Data provided
Educative measures
Active interventions
Outbreaks management
The teamThe teamThe teamThe team
Members of the ComiteeMembers of the Comitee
Expert ServicesExpert Services
AdministrationAdministration
Target ServicesTarget Services
AdministrationAdministration
Expert Services representativesExpert Services representatives
Preventive Medicine
Microbiology
Infectious DiseasesInfectious Diseases
Intensive Care
Pharmacy
Target ServicesTarget Services
Medicine
Surgery
Obstetrics & GynecologyObstetrics & Gynecology
Pediatrics and Neonatology
Onco-Hematology
Emergency Department
AdministrationAdministration
Medical Director
Head Nurse
EngeneeringEngeneering
Administration&Economics
Main Provider
The team operationThe team operationThe team operationThe team operation
Operative systemOperative system
AssesAsses ActActAsses Act
Wilson’s systemWilson’s system
6 step procedure:
1.- To select an objective
2.- To design a method to reach it
3.- To select one or more indicators
6 step procedure:
1.- To select an objective
2.- To design a method to reach it
3.- To select one or more indicators 3.- To select one or more indicators
4.- To plan data collection
5.- To prepar a graphic display of data
6.- To make a distribution list of results
3.- To select one or more indicators
4.- To plan data collection
5.- To prepar a graphic display of data
6.- To make a distribution list of results
Main objectives Main objectives
1.- To keep the Prevalence of Nosocomial Infections under 7%
2.- To keep figures of SSI after clean surgery with prosthesis implantation under 2%.
1.- To keep the Prevalence of Nosocomial Infections under 7%
2.- To keep figures of SSI after clean surgery with prosthesis implantation under 2%.2%.
3.- To achive figures of incidence density of VAP < 10 episodes/1000 days
4.- To reduce incidence density of CR-BSI < 2 episodes/1000 days
2%.
3.- To achive figures of incidence density of VAP < 10 episodes/1000 days
4.- To reduce incidence density of CR-BSI < 2 episodes/1000 days
Main objectives Main objectives
5.- To keep <1% the proportion of patients with a bladder catheter and an Open system of drainage
6.- To reduce the incidence of episodes of MRSA bacteremia
5.- To keep <1% the proportion of patients with a bladder catheter and an Open system of drainage
6.- To reduce the incidence of episodes of MRSA bacteremiaof MRSA bacteremia
6.- To reduce the incidence of episodes of episodes of ESBL-Gram negative bacteremia of nosocomial acquisition
7.- To reduce the incidence of P. aeruginosa and other NF-GNR bacteremia
of MRSA bacteremia
6.- To reduce the incidence of episodes of episodes of ESBL-Gram negative bacteremia of nosocomial acquisition
7.- To reduce the incidence of P. aeruginosa and other NF-GNR bacteremia
Main objectives Main objectives
8.- To reduce the incidence of CDI infections of Nosocomial Origin
9.- To reduce the incidence of Candida fungemia
10.- To reduce the percent of inadequate
8.- To reduce the incidence of CDI infections of Nosocomial Origin
9.- To reduce the incidence of Candida fungemia
10.- To reduce the percent of inadequate 10.- To reduce the percent of inadequate antimicrobial use for surgical prophylaxis
11.- To reduce the therapeutic misuse of antibiotics for nosocomial infections
12.- To reduce the inadequate use of antifungal agents and the overall expenses in antifungals
10.- To reduce the percent of inadequate antimicrobial use for surgical prophylaxis
11.- To reduce the therapeutic misuse of antibiotics for nosocomial infections
12.- To reduce the inadequate use of antifungal agents and the overall expenses in antifungals
Working (Study) groupsWorking (Study) groups
Surviving Sepsis Surviving Sepsis
Severe Pneumonia Severe Pneumonia
Osteoarticular Infections Osteoarticular Infections Microb
iologyMicrob
iology
Preventive
Medicine
Preventive
Medicine
Osteoarticular Infections
Collaboration in MycologyCollaboration in Mycology
Antibacterial controlAntibacterial control
Intravascular DevicesIntravascular Devices
Microb
iologyMicrob
iology
Preventive
Medicine
Preventive
Medicine
Working (Study) groupsWorking (Study) groups
Hematology-OncologyHematology-Oncology
Solid Organ TransplantationSolid Organ Transplantation
Clostridium difficileClostridium difficile
Microb
iologyMicrob
iology
Preventive
Medicine
Preventive
Medicine
Pediatric InfectionsPediatric Infections
Surgical Site InfectionsSurgical Site Infections
Bladder catheter and UTIBladder catheter and UTI
Microb
iologyMicrob
iology
Preventive
Medicine
Preventive
Medicine
Data to be provided by different groups
Data to be provided by different groupsdifferent groupsdifferent groups
Episodes of significant bacteremiaEpisodes of significant bacteremia
113 116124,5
134,3136,5148
170
186180
167155
178
165177
160
140134
161 161 161156
131
160 159169
139148
165
140
120
140
160
180
200
113 116
0
20
40
60
80
100
120
med
-00
med
-01
med
-02
med
-03
med
-04
med
-05
med
-06
med
-07
E-2
008 F M A M J
JL A S O N D
E-0
9 F M A M J
JL A S
60
80
100
120
Microorganisms of Bacteremic EpisodesMicroorganisms of Bacteremic Episodes
0
20
40
Hong 2,5 4 5,1 4,6 4,3 4 7,7 11 11 4 10 10 10 10 4 4 9 5 12 5 7 8 4 2 8 11 10 7 4 8 4 14
Anae 4,3 6 5,6 5,3 7,8 7,6 7,2 7,6 4 5 6 6 4 7 4 6 1 8 13 5 4 9 3 3 7 5 8 8 0 6 12 3
G (-) 51 56 65 64 74 76 88 90 70 84 62 82 84 86 74 74 67 77 77 52 62 59 71 57 69 59 64 86 73 70 73 85
G(+) 69 66 70 80 71 74 86 95 114 87 89 102 80 97 85 65 76 82 81 114 105 67 104 111 109 80 84 81 79 83 74 92
m00
m01
m02
m03
m04
m05
m06
m-07
E-08
F M A M J JL A S O N DE-09
F M A M J JL A S O N D
20
25
30
35
S. aureus bacteremia and MRSAS. aureus bacteremia and MRSA
0
5
10
15
S. aureus 17 17 18 21 16 17 19 19 16 22 17 14 9 23 15 16 16 15 12 22 16 14 23 30 29 17 18 21 21 18 14 26
SAMR 7 8 6 9 6 7 6 8 6 4 4 3 3 6 3 5 5 6 3 5 5 2 3 5 10 6 5 8 6 4 7 7
m00
m01
m02
m03
m04
m05
m06
m07
E-08
F M A M J JL A S O N DE-09
F M A M J JL A S O N D
HemocultivosBacteriemia por Klebsiella spp.
HemocultivosBacteriemia por Klebsiella spp.
1010,6
9,7
13
16
12
10
16
1010
1314
13
11
15 15
12
14
16
18
6,78
10
8,6 8,69,7
9 9
67
10 1010
4
7
3
9 9 9
7 7
0
2
4
6
8
10
m00m01m02m03m04m05m06m07 E-08
F M A M J JL A S O N D E-09
F M A M J JL A S O N D
HemocultivosFungemia
HemocultivosFungemia
11 11
10 10 10 10
9
1211
10
14
10
12
14
16
2,5
3,8
5,14,6
4,2 4
7,7
4 4 45 5
78
4
2
87
4
8
4
0
2
4
6
8
m00m01m02m03m04m05m06m07 E-08
F M A M J JL A S O N D E-09
F M A M J JL A S O N D
Data provided monthly by MicrobiologyData provided monthly by Microbiology
Patients with Blood cultures requestPatients with Blood cultures requestEpisodes of nosocomial bacteremiaS. aureus BSINosocomial BLEE producing bacteremiaEpisodes of Pseudomonas bacteremiaEpisodes of fungemiaEpisodes of fungemiaEpisodes of catheter-related BSIEpisodes of BSI in I.C.U.Episodes of CDIPatients with MRSAPatients with ESBL infections (nosocomial)
Data provided monthly by MicrobiologyData provided monthly by Microbiology
LRT secretions from ICU’s with significant LRT secretions from ICU’s with significant bacteria
Positive prosthetic joint samples
Episodes of Invasive Aspergillosis
Operating Rooms with “unclean air”Operating Rooms with “unclean air”
Positive IV catheter tips. Distribution of microorganisms and Units
Bacteriuria of hospitalized patients
High-Parade Microorganisms and susceptibility
MDR microorganisms in high-risk unit
1,00
1,20
1,40
Episodios/1.000 estancias
Clostridium difficile Clostridium difficile toxigénicotoxigénicoDensidad de incidencia (interanual)Densidad de incidencia (interanual)Clostridium difficile Clostridium difficile toxigénicotoxigénicoDensidad de incidencia (interanual)Densidad de incidencia (interanual)
0,00
0,20
0,40
0,60
0,80
En98Jl
98En
99Jl
99En
00Jl
00En
01Jl
01En
02Jl
02En
03Jl
03En
04Jl
04En
05Jl
05En
06Jl
06En
07Jl
07En
08Jl
08En
09Jl
09
Episodios/1.000 estancias
HGUGM
Pacientes con aislamiento de hongos filamentosos
20
25
30CasosPacientes
0
5
10
15
20
Casos 1,25 2 3 1 2 1 3 2 2 1 1 2 4 2
Pacientes 11 14,3 21 18 16 17 16 11 9 9 7 21 14 13
Media 08
Media 09
Enero Febr. Marzo Abril Mayo Junio Julio Agos. Sept. Oct. Nov. Dic.
Casos de micosis filamentosas
MUCORMICOSIS4 (16%)
AI/ESCEDOSP1 (4%)
AI/MUCORM.1 (4%)
ESCEDOSPO.3 (12%) AI
16 (64%)
Servicios de pacientes con IFIs
10
12
1452%
5
2 21
13
20
2
4
6
8
10
Digestivo Geriatria Oncohemato Onco UVIS Otros
Microorganism Pen Oxa Lin Vanc Dapt Tig
S. aureus
Data provided monthly by Microbiology% Susceptibility
Data provided monthly by Microbiology% Susceptibility
S. aureus
C.N.S.
Enterococcus
S. pneumoniae
Microorganism Cef1 Ceftr Cefta Cipr Toba AK
E. coli
Enterobacter
Data provided monthly by Microbiology% Susceptibility
Data provided monthly by Microbiology% Susceptibility
Klebsiella
P. aeruginosa
A. baumanii
Microorganism Fluco Vori Posa Candin AmB
C. albicans
C. parapsilosis
Data provided monthly by Microbiology% Susceptibility
Data provided monthly by Microbiology% Susceptibility
C. tropicalis
C. glabrata
C. krusei
Data provided by Preventive MedicineData provided by Preventive Medicine
Surgical site infections (clean surgery)
Surgical site infections (non-clean)
Yearly Point Prevalence Study of NI
Outbreaks (solved and active)
Data provided by Pharmacy and AbxData provided by Pharmacy and Abx
Prevalence study of Antimicrobial agents
For prophylaxis
For treatment
Antibiotic misuseAntibiotic misuse
DDD’s of Antibacterials/1000 admissions
Distribution of DDD’s per Unit
Distribution per antibiotic families
Cost of buying antibacterials
Data provided by Pharmacy and AbxData provided by Pharmacy and Abx
DDD’s of antifungals
For prophylaxis
For treatment
Antibiotic misuse
DDD’s of Antifungals /1000 admissions
Distribution of DDD’s per Unit
Distribution per antifungal families
Prevalence study of bladder catheterizationPrevalence study of bladder catheterization
Catheterized patients/1000 admissions
% of bacteriuric patients
Inadequate catheterization
% Closed system
Inadequate handling of urine bag
Data provided by Surviving sepsisData provided by Surviving sepsis
Lactate determinations/1000 admissions
Evolution of sepsis alarm
Evolution of Sepsis alerts in Emergency Evolution of Sepsis alerts in Emergency
Department
Delay between antibacterial prescription
and antibacterial administration
Microbiological alerts
373
323 326
365
396374
395
346
392
318
363341
362
300
350
400
450
500
Severe Pneumonia Group (ICU’s)Days of stay and admissionsSevere Pneumonia Group (ICU’s)Days of stay and admissions
245
52 5037
57 51 58 51 5228
58 62 59 5146
0
50
100
150
200
250
300
N08
D08
E09
F09 M09 A09MY09
J09
JL09 A09
S09 O09 N09
D09
Estancias Ingresos
333343
309
359
387
356
395
332
382
311326 325
339327 325 324
345
378
352
452
312
379
301314 313
348
350
400
450
500
Severe Pneumonia Group (ICU’s)Days of mechanical ventilationSevere Pneumonia Group (ICU’s)Days of mechanical ventilation
159 157
182
209 213
189
216
245
204
142 143
105
172 177
242240
301
0
50
100
150
200
250
300
N08 D08 E09 F09 M09 A09 M09 J09 JL09 AG09 S09 oct-09 N09 D09
Días VM Días CVC Días SV
182
209 213
189
216
245
204
172 17737,03200
250
300
40
50
60
Severe Pneumonia Group (ICU’s)Incidence density of VAPSevere Pneumonia Group (ICU’s)Incidence density of VAP
159 157142 143
105
172
14
2
75 4
8
35
13 2 3 46,28
25,47
10,98
33,49
23,4721,16
37,03
12,24
24,5
7,04
20,9719,04
17,4
24,56
0
50
100
150
N08 D08 E09 F09 M09 A09 MY09 J09 JL09 A09 S09 O09 N09 D09
0
10
20
30 %
Días VM NAVM/1000d Lineal (NAVM/1000d)
Other Data provided by the Severe Pneumonia GroupOther Data provided by the Severe Pneumonia Group
% patients under MV with semirecumbent
position
% of patients with C.A.S.S.
% patients with oral hygiene with
chlorhexidine
Data provided by IV Catheter GroupData provided by IV Catheter Group
Episodes of CR-BSI/1000 days of
exposure
Implantation bundle fulfilled and signed
Maintainance bundle fulfilled and signed
356
387
359
309
352
304
10,12250
300
350
400
10
12
14
Severe Pneumonia Group (ICU’s)Incidence density of CR-BSISevere Pneumonia Group (ICU’s)Incidence density of CR-BSI
2
0 0
1
2
1
4
0
3
0
1
2
0
22,78
5,16
2,8
0
7,85
0
3,21
6,13
0
5,89
00
5,68
0
50
100
150
200
250
N08 D08 E09 F09 M09 A09 MY09 J09 JL09 A09 S09 O09 N09 D09
0
2
4
6
8
Días expos.catéter Epi/ BRC/1000d
Educative InterventionsEducative InterventionsEducative InterventionsEducative Interventions
Educative InterventionsEducative Interventions
Preventive MedicinePreventive MedicineA permanent course on Hand Hygene
Microbiology:Microbiology:Course of Treatment of Infections (yearly)
Contributions to the other courses
Internal Medicine and EmergenciesInternal Medicine and EmergenciesInfectious Disease Emergencies
Contributions to the other courses
Surviving SepsisSurviving SepsisSurviving Sepsis Principles
Management of Infective Endocarditis
Educative InterventionsEducative Interventions
Severe PneumoniaSevere PneumoniaManagement and Prevention of Nosocomial Pneumonia
Osteoarticular infectionsOsteoarticular infectionsA one day activity on the management of Osteoarticular InfectionsA one day activity on the management of Osteoarticular Infections
Collaboration in MycologyCollaboration in MycologyA course of 2 days on systemic mycosis: treatment and prevention
Intravascular DevicesIntravascular DevicesManagement of Catheter Related Infections.
Working (Study) groupsWorking (Study) groups
Solid Organ TransplantationSolid Organ TransplantationPrevention and management of Infections in SOT and Immunocompromissed patients
Pediatric InfectionsPediatric Infections
Pediatric nosocomial infectionsPediatric nosocomial infections
Surgical Site InfectionsSurgical Site InfectionsPrevention and treatment of Surgical Site Infections
Bladder catheter and UTIBladder catheter and UTIUTI: Prevention and management
Active Interventions: MicrobiologyActive Interventions: Microbiology
Early Diagnostic procedures
Selection of diagnostic techniques
Improvement in communication (telephone)
Selection of antibiotic formulary
Restriction of antibiotic information
Early Diagnostic procedures
Selection of diagnostic techniques
Improvement in communication (telephone)
Selection of antibiotic formulary
Restriction of antibiotic informationRestriction of antibiotic information
Adequacy of sepsis treatment
Computer-Assisted strategies
Telephonic antibiotic consultation
Triggering non-requested ID consultations
Restriction of antibiotic information
Adequacy of sepsis treatment
Computer-Assisted strategies
Telephonic antibiotic consultation
Triggering non-requested ID consultations
OutbreaksOutbreaksOutbreaksOutbreaks
Role in outbreaksRole in outbreaks
Microbiology:
Rapid identification of the problem
Environmental culturesEnvironmental cultures
Genotyping of microorganisms
Participation in the “Crisis cabinet”