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What Every Health Care Executive Should Know: The Cost of Antibiotic Resistance

Stephen G. Weber, MD, MSAssistant Professor

Section of Infectious DiseasesMedical Director of Infection Control and Clinical Quality

University of Chicago Medical Centerand JCR Consultant – Infection Prevention and Control Services

Chapter 5: Antibiotic Stewardship

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Is antibiotic misuse promoting the spread of MDROs and increasing costs at your hospital?

– Dr. Anderson admitted an elderly nursing home patient to your hospital with pneumonia. He ordered blood cultures and an antibiotic (moxifloxacin), which the patient began three hours after admission. In spite of the antibiotic, the patient’s condition worsened. The microbiology reports were returned the next day and showed that the blood cultures were growing Pseudomonas aeruginosa resistant to moxifloxacin but susceptible to imipenem.

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– Dr. Anderson changed the antibiotic to imipenem as soon as the test results became available. The patient was transferred to the intensive care unit (ICU) where she worsened and required mechanical ventilation. She spent two weeks in the ICU before being transferred to the internal medicine service.

Is antibiotic misuse promoting the spread of MDROs and increasing costs at your hospital?

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Is antibiotic misuse promoting the spread of MDROs and increasing costs at your hospital?

– The patient was finally transferred back to her nursing home after a 24-day hospital stay. The total cost of her admission was more than $100,000.

– Dr. Anderson later learned that nearly all of the patients admitted from that particular nursing home with infection ended up requiring treatment with broad-spectrum antibiotics because of a high frequency of multidrug-resistant organisms (MDROs).

– Are you sure that antibiotics are used judiciously at your hospital?

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Objectives

– To describe the role of antibiotic abuse and misuse in the spread of MDROs in hospitals

– To describe the structure and functions of an effective antibiotic stewardship program.

– To provide an introduction to the costs and potential savings associated with an effective stewardship program

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Antibiotic Misuse, Abuse and MDROs

– The use of antibiotics, even when well-intentioned and clinically appropriate, promotes the selection of MDROs– Exposure to antibiotics, which kill susceptible bacteria, permits the

survival of strains with the genetic capacity to evade or elude the effect of the antibiotics

– Broad-spectrum antibiotics, which are most commonly prescribed in the hospital, are especially associated with the selection of MDRO

– In the hospital setting, it has been estimated that up to one-half of antibiotic use is unnecessary

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Do You Know What You’re Spending to Treat Resistant Organisms?

Expenditures for drug classes used to treat resistant organisms greatly increased from 2004 to 2007In contrast, expenditures for older drug classes (eg, penicillins, fluoroquinolones) decreased over the same period

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CarbapenemsAnti-MRSA Drugs*GlycylcyclinesPenicillinsFluoroquinolones

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Antibiotic Stewardship Program (ASP) Overview– Antibiotic stewardship is a multisystem team

approach that involves limiting inappropriate use of antibiotic agents while optimizing the selection, dose, duration and route of therapy with the most appropriate drug for the patient’s condition

– ASPs have been associated with 22-36% reductions in antibiotic use and are associated with numerous clinical benefits

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Structure of an Effective ASP

– Broad-based membership– Infectious Diseases clinician and pharmacist, medical staff

members, microbiologist, pharmacists, information systems expert, infection preventionist and/or healthcare epidemiologist

– Regular meetings– Policy and performance improvement initiatives– Plans for disseminating new interventions to frontline clinicians

– Integrated into Medical Staff Organization– Report through Pharmacy and Therapeutics Committee

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Functions of an Effective ASP

– Review of Pharmacy Data– Information about antibiotic utilization can be used to document

and analyze trends within the hospital and to benchmark against external or historical standards

– Precise and established methods exist for documenting and reporting antibiotic utilization data. – “Defined daily doses” can be determined for any antimicrobial

agent and adjusted for hospital size and census

– Trends in drug acquisition and seasonal variation in usage must be accounted for in any rigorous analysis of antibiotic utilization

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Antibiotic Utilization Example

Cefazolin is administered 1 g every 8 hours.Defined daily dose (DDD) = 3431 days of cefazolin administered during quarter 1 (1,292 DDD)200 bed hospital @ 90% capacity = 16,560 patient days

78.0 DDD/1,000 patient days

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Functions of an Effective ASP– Review of Clinical Microbiology Data

– Antibiotic utilization data documents one cause of MDRO spread in hospitals. The effect of misuse and abuse is best measured through examining trends in the frequency of MDRO

– Most hospitals generate a summary of antibiotic susceptibility patterns (Antibiogram) at least annually– The antibiogram is an essential tool for setting antibiotic

policy and for decision-making at the bedside

– Susceptibility data must be collected and reported in a rigorousfashion and should serve as the basis for performance improvement initiatives.

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Functions of an Effective ASP– Integrating Data and Implementing Change

– Analysis of utilization and susceptibility data may prompt both recommendations for antibiotic stewardship and infection control– Changes should be approached cautiously and with

sensitivity to the expectations of the clinical staff– Consider promoting efforts related to clinical quality and

patient safety, rather than exclusively on cost savings

– Education and Guidelines– Guidelines promoting rational and appropriate antibiotic use

should be widely disseminated– Consider a focus on duration of antibiotic therapy

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Functions of an Effective ASP– Formulary Decisions and Antibiotic Restriction

– An important, albeit unpopular stewardship tool– Limits clinicians in terms of antibiotic prescribing privileges– May be associated with unintended epidemiologic

consequences

– Review and Feedback of Antibiotic Use– May be done in aggregate or for individual clinicians

– Target “problem prescribers”

– Computerized Order Entry– Nearly limitless stewardship opportunities

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Costs and Savings of ASP– Savings in the range of 20-35% have been reported

– Mostly realized through reduced acquisition costs– Indirect savings may also be achieved

– ASP costs mostly driven by salaries and support for ASP leaders and participants– Consider 0.5 FTE for a physician and 1.5 FTE for pharmacists

– Hospital pharmacy budget may provide information about potential cost savings– Antibiotic drugs should make up no more than 18% of the total

pharmacy budget

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Overview of Tools

– Antibiogram Template

– Proactive Strategies for ASPs

– Antibiotic Audit Form

– Competency Questions

– CEO Talking Points

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Antibiogram Template

– Get the information where it’s needed – in the hands of clinicians who prescribe antibiotics– The template provides a standardized summary of which antibiotics

are most effective at your organization

– Brief information about stewardship isolation precautions included

– The template can be customized for nearly any population depending on the needs and desires of clinicians– Available as both a tri-fold pocket resource and for distribution

electronically

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Antibiogram TemplateSample Tool

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Proactive Strategies for ASPs

– This document summarizes the strategies for implementing an ASP using guidelines from the Infectious Diseases Society of America (IDSA) and the Society for Healthcare Epidemiology of America (SHEA)

– Prioritizes “core” versus supporting strategies using IDSA-US Public Health Services rating scale

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Proactive Strategies for ASPs

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Antibiotic Audit Form

– In the hands of a sophisticated reviewer, this tool forms the basis of building a comprehensive overview of the appropriateness of antibiotic use

– Use aggregate data to inform stewardship policy, as the basis for educational and improvement initiatives or to quantify the impact of such programs

– Use individual data to identify “problem prescribers”

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Antibiotic Audit FormSample Tool

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Competency Questions

– It is difficult for prescribers to keep up with the latest new drug agents and trends in antimicrobial resistance– Knowledge can really be power when it comes to MDRO

prevention!

– ASP Competency Questions can be readily adapted to any teaching format or forum currently employed for prescribers at your hospital

– ASP Competency Questions offer the opportunity to tailor the message and really help our colleagues understand that MDRO control IS their job.

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Competency QuestionsSample Tool

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CEO Talking Points

– Even those who will never write a prescription have a stake in rational and appropriate antibiotic use

– These talking point stress the universal interest we share in rational prescribing– Your doctors and other prescribers need to know that irrespective

of his or her clinical background, your senior executive really understands the risk

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CEO Talking PointsSample Tool

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For More Information:

– Visit Our Website: http://www.jcrinc.com/MDRO-Toolkit/

– Contact:JCR’s Consulting Services Group

630-268-7400 ConsultingServices@jcrinc.com

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What Every Health Care Executive Should Know: The Cost of Antibiotic

Resistance– Joint Commission Resources (JCR), supported in part by funding from Ortho

McNeil, Division of Ortho-McNeil-Janssen Pharmaceuticals, Inc., is privileged to announce the release of What Every Health Care Executive Should Know: The Cost of Antibiotic Resistance, an innovative, evidence-based, and practical collection of senior leadership resources.

– This manual is presented to your institution as an informational tool only. JCR is solely responsible for the development and contents of this tool. You are solely responsible for any decision to use the manual as a guideline for assisting your institutions in establishing safe infection control practices. Obviously, it is only a guideline and you would have to make the decision as to whether it needs to be tailored to fit the practices and settings at your individual institution. JCR’s production of this manual for Ortho-McNeil, Inc. is on a non-exclusive basis, and is not an endorsement of that company or its products, or a statement that its expertise or products are superior to those of other comparable companies. JCR will make available all the subject matter contained in the Infection Prevention and Control Toolkit and Workshops to any other party interested in furthering JCR’s efforts to help improve quality and safety.