A Call For Stewardship

1
A Call For Stewardship

• MN Chapter of the Association of Professionals in
  Infection Control and Epidemiology (APIC)
• September 28, 2009
• Kimberly Boeser, ID PharmD.
• University of Minnesota Medical Center, Fairview

2
Objectives

• Define stewardship and Antimicrobial
  Stewardship
• Review Infectious Disease Society of America
  (IDSA) and Society of Healthcare Epidemiology in
  America (SHEA) 2007 Guidelines for Antimicrobial
  Stewardship
• Steps for development of a stewardship
  program-getting started
• Overview of keys for implementation success
• Goals, roles and procedures of an antimicrobial
  stewardship program
• Measurements outcomes
• Obstacles, triumphs and the future

3
Healthcare-associated Infections the Impact

• CDC focuses on healthcare-associated infections
• how they happen?
• develop appropriate interventions
• A report from CDC updates previous estimates of
  healthcare-associated infections
• 32 UTI
• 22 SSI
• 15 PNA
• 14 bacteremias
• Healthcare-associated infections
• account for an estimated 1.7 million infections
• 99,000 associated deaths each year
• Total cost annually 5 billion

4
Background-A Need for Stewardship

• Increasing prevalence of resistant bacteria
• Multi-Drug Resistant Organisms (MDRO)
• MRSA, VRE, VRSA/VISA, C.diff, GNB (ESBLs, KPCs)
• Over the past decades MDRO have steadily been
  rising
• Increased morbidity and mortality
• Increased Antimicrobial expenditures
• Decrease in market research and development
• Very few antimicrobials are currently in the
  pipeline
• takes 10 years to bring a new agent to market
• An investment of 800 million to 1.7 billion
• 56 decrease in antimicrobial approval from the
  FDA (1983-87 to 1998-2002)
• Focus of National Quality Organizations
• Institute for Healthcare Improvement (IHI)
• JCAHO National Patient Safety Goal

5
Increasing prevalence of resistant bacteria
Increased morbidity and mortality
6
Methicillin Resistant S. aureus (MRSA)-Hospital
Acquired

• First isolates of MRSA reported in 1968
• CDC reported 2 staphylococcal infections were
  MRSA in 1974
• 1990s-Alarmingly increased to 20-25
• 1999-reported as gt50
• 2003-NNIS reported at 59.5 in ICUs
• High fatality for certain MRSA infections
• Bacteremia
• Poststernotomy mediastinitis
• Surgical site infections
• Mortality may increase with S. aureus isolates w/
  reduced susceptibilities
• MIC creep
• CoNS (S. epidermidis) MIC gt2
• VISA or VRSA
• Treatment failures

7
Vancomycin Resistant Enterococcus (VRE)

• Enterococci leading cause of many infections
• Nosocomial bacteremia
• Surgical wound infections
• Urinary tract infections
• Third most acquired nosocomial infection
• Reported as 10-12
• Inhabit the bowel
• Hardy organisms-tolerate many environments
• Most enterococcal infections are due to
• E. faecalis -isolated from 80 of human
  infections
• E. faecium
• Mortality Rates of 60-70 directly related to VRE

8
ESBL Gram Negative bacilli

• Similar adverse outcomes reported with antibiotic
  resistant GNR bacteria
• Increasing resistance to beta lactams,
  fluoroquinolones, aminoglycosides and even
  carbapenems
• 1997 SENTRY Antimicrobial Surveillance Program
  K. pneumoniae resistance rates to Ceftaz and
  other 3rd generation cephalosporins
• Bacteremia 6.6
• Pneumonia 9.7
• Wound infections 5.4
• UTI 3.6
• 2003 NNIS ICU isolates of K. pneumoniae
  resistance reported to same drugs
• 20.6

9
(No Transcript)
10
Stewardship

• -the conducting, supervising, or managing of
  something especially  the careful and
  responsible management of something entrusted to
  one's care

11
Antimicrobial Stewardship

• What??? Is often the response
• Definition the appropriate selection, dosing,
  route and duration of antimicrobial therapy

12
Antimicrobial Stewardship-Goals

• Primary Goal optimize clinical outcomes, while
  minimizing unintended consequences of
  antimicrobial use
• Toxicity
• Selection of pathogenic organisms (MRSA, VRE,
  ESBL gram negative bacteria)
• Emergence of RESISTANCE
• Secondary Goal reduce health care costs w/out
  adversely impacting quality of care

13
(No Transcript)
14
(No Transcript)
15
Antimicrobial Stewardship-Support

• Infectious Diseases Society of America and the
  Society for Healthcare Epidemiology of America
  Guidelines for Developing an Institutional
  Program to Enhance Antimicrobial Stewardship CID
  2007
• Support
• American Academy of Pediatrics
• American Society of Health-System Pharmacists
• Infectious Diseases Society for Obstetrics and
  Gynecology
• Pediatric Infectious Diseases Society
• Society for Hospital Medicine
• Society of Infectious Diseases Pharmacists
• Society for Healthcare Epidemiology of America
• Infectious Diseases Society of America

16
How did we get started?
17
Background and a Call for a Stewardship Program

• Proposal developed and presented to senior
  leadership for approval
• UHC best practices, resistance trends, costs
• Recommendations included 1.0 FTE Pharmacist,
  0.5 FTE Medical Staff
• 0.35 FTE medicine
• 0.15 FTE pediatrics
• Covered the responsibilities of the service,
  measurements and implementation plan

18
Costs Analysis

• UMMC, Fairview has a 32 million operating drug
  budget
• Anti-infectives accounted for 10 of the total
  budget
• Compared to UHC Best Practices UMMC, Fairview ABx
  /patient day were higher than average

19
(No Transcript)
20
(No Transcript)
21
Antimicrobial Management Team-UMMC, Fairview
Key Components

• Action Plan for Implementation
• January 2007
• Development of Guidelines for restricted
  antibiotics
• Patient Monitoring Forms/Review Process
• Education to medical and pharmacy staff
• Rounds with Medicine ID, Surgical ID, and
  Pediatric ID
• Establish Measurements
• Obstacles-predict
• Outcomes

22
Getting Started

• Identify the problems with our old system
• Creating a policy- Antimicrobial Stewardship
  Restricted Anti-infective Agents
• Generate a list to flag the restricted
  antibiotics
• 20 restricted agents
• spectrum of activity, potential for emergence of
  resistance, adverse effect profiles and cost
• Establish interventions
• 12 interventions
• Develop monitoring tool
• Create antibiotic guidelines for each agent

23
Interventions

• Change to more appropriate antibiotic based on
  lab data
• Change to alternative unrestricted anti-infective
• Discontinue one or more antibiotics (PO or IV)
• Change from IV to PO antibiotics
• Better empiric antibiotic therapy
• Antibiotic dosage change
• Consult recommended (eg. Infectious Disease,
  Pulmonary/Critical Care, Renal, Urology, etc.)
• Additional/Further diagnostic testing recommended
• Simplify antibiotic regimen (eg. Inpatients on
  redundant or excessively broad spectrum
  antibiotics
• Recommend change in post-op antibiotic duration

24
Antibiotic Guidelines

• Address the following
• Reason for restriction of agent
• FDA Approved Indications
• UMMC/UMCH, Fairview Approved Indications
• Dosing recommendations
• Monitoring
• Cost information
• Antibiotic Guidelines printed into a booklet that
  was distributed to medical students, medical
  residents, medical staff, pharmacy staff and
  students

25
Education/Communication

• to Medical Staff and Residents and Pharmacy Staff
• Presentation to Medical Grande Rounds
• Presented and distributed the Guideline Booklets
  to medical residents and pharmacy
• Met with unit/department medical directors
• Education/presentation to pharmacy staff

26
Role of the AMT

• Daily rounds with medicine and surgery
• Tuesday/Thursday rounds with Pediatrics
• Review all patient data and antibiotics
• Do restricted agents meet our guidelines for use?
• Verbal and written recommendations
• Electronic notes
• Talk to the primary teams
• Follow up in 24 hours that recommendation were
  accepted
• If not, address the issue with the teams
• Pharmacist and Staff Physician discuss with
  Primary team Staff

27
Measurements/Outcomes

• Monthly antibiotic utilization
• Number of doses dispensed
• Antibiotic cost per patient day
• Interventions and acceptance rates
• Average number of antibiotics
• Per patient day
• Per patient visit
• Correlation with resistance patterns

28
Utilization of Anti-infectives-Hurdles

• Increase of 3,200 patient days from 2006 to 2007
• Expansion of our Adult Bone Marrow Transplant
  unit
• Antibiotics prescribing opened for upfront use
  with no restriction
• New class of medical residents not all aware of
  the guidelines for use of restricted agents

29
Implementation of Stewardship Program January
2, 2007
30
(No Transcript)
31
Antimicrobial Cost per Patient Day (2005-2008)
32
Intervention Data (2007)
33
Obstacles

• Gaining trust of the primary teams
• Recommendations taken and changes made within
  24-48 hours
• Overcoming the idea this is only a cost savings
  project
• Conversion from paper notes to electronic record
  /-
• Information systems Tracking resistance rates

34
Keys To Success

• ID staff support, medical unit director support,
  department director support
• Communication to primary teams
• Recommendations that are evidence based and
  follow national guidelines
• Collaboration Multidisciplinary Approach
• DATA, DATA, DATA !!!
• Show me the
• Keeping in mind, What is best for our patients
  as a whole
• Early wins

35
Future Plans

• Clinical Measurement Plan
• Expansion of other antibiotics
• Development of Clinical Pathways for disease
  states
• Annual update of Antimicrobial Guideline Booklet
• Incorporate our guidelines into electronic
  ordering
• Expansion of Stewardship Program to other
  Fairview System Hospitals
• Publishing our data including cost and impact of
  antimicrobial utilization on resistance trends

36
Last Thought

• When you want to cook a frog, they say, dont
  throw it into boiling water-it will only jump
  out. Instead place the frog in tepid water and,
  ever so slowly increase the heat. Extending the
  Cure Campaign
• Much like the frog, our awareness of resistance
  (danger) is there. The steady increase of
  resistance is knownbut are we waiting for a
  crisis to respond?

37
Acknowledgements

• Department of Pharmacy
• Pam Phelps
• Infection Prevention Department
• Chris Hendrickson
• Anita Guelcher
• Sue Garayalde
• Dept. of Surgery, Pediatrics and Medicine
  physicians who have participated with AMT
• Greg Beilman, Matthew Byrnes, Jeff Chipman
• Mark Schleiss, Mark Robein, Pat Ferierri
• Phil Peterson, Susan Kline, Winston Cavert, Paul
  Bohjanen, Dave Boulware, Bryan Rock, Tim
  Schacker, Mark Cannon, David Strike

38
References

• Dellit TH, Owens RC, McGowan JE, et al.
  Infectious Diseases Society of American and the
  Society for Healthcare Epidemiology of America
  Guidelines for Developing an Institutinal Program
  to Enhance Antimicrobial Stewardship. CID.
  2007 44 000.
• National Institute of Allergy and Infectious
  Diseases. The problem of antibiotic resistance.
  www.niaid.nih.gov/factsheets/antimicro.htm
  (accessed 2006 Nov).
• Centers for Disease Control and Prevention.
  National Nosocomial Infections Surveillance
  (NNIS) System report, data summary from January
  1992 through June 2004, issued October 2004.
  www.cdc.gov/ncidod/dhap/pdf/nnis/2004NNISreport.pd
  f (accessed 2006 Nov).
• Infectious Diseases Society of America. Bad
  bugs, no drugs. As antibiotic discovery
  stagnatesa public health crisis brews.
  www.idsociety.org/pa/IDSA_Paper4_final_web.pdf
  (accessed 2006 Nov).
• Centers for Disease Control and Prevention.
  Management of Multidrug-Resistant Organisms In
  Healthcare Settings, 2006. www.cdc.gov/ncidod/dhqp
  /pdf/ar/mdroGuideline2006.pdf (accessed 2006
  Nov).
• Turck C et al. Novel Agents for the Treatment of
  Methicillin-Resistant Staphylococcus aureus
  (MRSA) and Vancomycin Resistant Enterococci
  (VRE). University HealthSystem Consortium-Drug
  Monographs. 2006 Dec 1-46.
• Wenzel RP. The Antibiotic Pipeline-Challenges,
  Costs and Values. N Engl J Med. 2004
  351(6)523-26.
• Nelson R.. Antibiotic development pipeline runs
  dry. The Lancet. 2003 362 1726-27.
• Kollef MH, Sherman G, Ward S, et al. Inadequate
  antimicrobial treatment of infections a risk
  factor for hospital mortality among critically
  ill patients. Chest. 1999 115462-74.
• Scheetz MH, Hurt KM, Noskin GA, Oliphant CM.
  Applying antimicrobial pharmacodynamics to
  resistant gram-negative pathogens. Am J
  Health-Syst Pharm. 2006 63 1346-1360.
• Fridkin SK, hageman JC Morrison M, et al. for the
  Active Bacterial Core Surveillance Program of the
  Emerging Infections Program Network.
  Methicilin-resistant Staphylococcus aureus
  disease in three communities. N Engl J Med.
  2005352 (14) 1436-1444
• Aslam S and Musher, DM. An Update on Diagnosis,
  Treatment, and Prevention of Clostridium
  difficile-Associated Disease. Gastroenterol Clin
  N AM. 2006 35315-335.
• Blossom DB and McDonald LC. The Challenges
  Posed by Reemerging Clostridium difficile
  Infection. CID 200745000-000