How to Start an Antimicrobial Stewardship Program

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How to Start an Antimicrobial Stewardship Program

• In Conjunction with AzHHAs Safe and Sound
  Patient Safety Initiative
• Patty Gray RN, CIC Bill Wightkin, Pharm D, R.Ph

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Learning Objectives

• After listening to the presentation, viewing
  Power Point slides and participating in a
  question and answer session, the participant
  will
• A. Be able to list the recommended
  components of an antibiotic
• stewardship program
• B. Be able to detect antibiotic use
  improvement opportunities
• from the analysis of utilization data
• C. Be able to explain the barriers for
  successful
• implementation of such a program

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Presentation Outline

• I. Why Develop an Antimicrobial Stewardship
  Program?
• A. Infection control nurses perspective
• B. Hospital pharmacists perspective
• II. Recommended Components of a Program
• III. Scottsdale Healthcares Program
• A. Short history
• B. Committee membership and
  leadership
• C. Goals of the committee
• D. Activities-to-date
• E. Results so far
• F. Opportunities for improvement
• G. Next steps
• IV. Audience questions and answers

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Why Develop an Antimicrobial Stewardship Program

• From an Infection Preventionist Perspective
• Track and Reduce antimicrobial resistance
• Encourage appropriate treatment patterns The
  right antibiotic, for the right duration
• Develop a collaborative practice between
  MDs/LIPs, Pharmacy, Laboratorians and Infection
  Preventionists with best patient outcome in mind
• Education Catalyst

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Why Develop an Antimicrobial Stewardship Program?

• Hospital Pharmacists Perspective
• Allows needed FOCUS on a drug class
• Need to assure appropriate medication management
  and safety
• Assist with educational efforts
• Assist with formulary standardization
• Control costs

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Antimicrobial Purchases
Yearly Expense
Daptomycin 696,000
Pip/Tazo 585,000
Zyvox 444,000
Primaxin 415,000
Caspofungin 400,000
Levofloxacin 338,000
Invanz 335,000
Tygacil 284,000
Expense of Top 100 Drugs 17.5 million/yr
Antimicrobials 5 million/yr 29
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Recommended Components of an Antimicrobial
Stewardship Program

• Foundation 2 core, proactive strategies
• Prospective audit with intervention and feedback
• Formulary restriction and preauthorization

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Other Recommended Components of an Antimicrobial
Stewardship Program

• Standardized order sets and clinical pathways
• (foster evidence-based prescribing)
• Antimicrobial order forms
• De-escalation of therapy (Review CS results
  on-going review of therapy)
• Dose optimization (right dose for site of
  infection
• renal dose adjustment)
• IV to oral dose conversion

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Scottsdale Healthcares Program History

• Evolution from an Antibiotic Subcommittee of the
  PT Committee
• Perception of an Antibiotic Restriction and
  Control Approach
• Acknowledgement of Hospital and Community
  considerations
• Need for Administrative and Board Support
• Mission Development Educational/Cooperative
  Focus Stewardship
• University of Kentucky Program- Dr. R. Rapp
• New Hospital with need for guidelines upon
  opening of facility

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SHC Program Committee Membership and Leadership

• Medical Staff- Active participation is critical
  to success
• Includes Chief Medical Officer support, ID ,
  Hospitalists, Intensivists, Pulmonary, ED,
  Community MDs and others as willing
• Pharmacy- Coordinates the efforts of the team,
  guideline development, education and tracking
  reports
• Infection Prevention Control- Prevention
  Strategies, hand hygiene, precautions, medical
  staff-nursing laison
• Microbiology- Data trends, special testing
  expertise
• Quality Organizational Development- Performance
  Improvement guidance meeting guidance

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Goals of Committee

• Assist providers in appropriate use of
  antimicrobial therapy with improved patient
  outcomes
• Slow the development of antimicrobial resistance
• Develop evidence- based appropriate use
  guidelines
• Educate providers and staff regarding guidelines
• Track resistance patterns and report back to
  medical and hospital staff
• Report committee progress and outcomes to PT,
  and Executive Committees

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Activities to Date

• Developed guidelines for 4 antimicrobials
• Day 7 of therapy reminder to chart
• Day 10 of therapy phone call from pharmacy ID
  resident
• Drug utilization evaluation (DUE)

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Results so far (2 months of data)
Drug of patients with an Infectious Disease Physician Consultation Criteria Non-Conformance Rate
Caspofungin 100 (30 patients) 23 (no de-escalation to another agent with Candida albicans)
Daptomycin 93 (41 patients) 24 (no trial of vancomycin for skin infections)
Linezolid 82 (33 patients) 64
Tigecycline 79 (34 patients) 68
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Opportunities for Improvement

• DUE reveals significant non-conformance to
  adopted guidelines
• Are guidelines appropriate?
• It does not appear that ID physicians are
  sufficiently
• engaged in the stewardship activities
• Stewardship Foundation 2 core, proactive
  strategies
• Is our process ROBUST (interventions after
  7-10 days)??

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Barriers Opportunities for Improvement

• Cultural Perceptions- Medicines Heirarchy
• Integration of Team Approach and Evidenced Based
  Practice into culture
• Continued Involvement of Hospitalists Community
  MDs
• Infectious Disease MDs support, agreement use
  of guidelines
• Turnover of Pharmacy Leadership
• Ongoing Administrative Support

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Next Steps

• Re-evaluate physician leadership
• Formulary evaluation caspofungin vs. micafungin
  vs. anidulafungin
• Transition from faculty ID pharmacist leadership
  to
• SHC pharmacy clinical staff
• 4. Explore expansion of pharmacist clinical
  duties to include
• antimicrobial stewardship responsibilities
• 5. Improvement of the 2 core proactive strategies

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Next Steps

• ASK WHY...determine and address prime causative
  factors that have resulted in
• Antibiotic overuse
• Sub-optimal antibiotic selection
• Too long duration of therapy
• Lack of de-escalation to more appropriate agents
• Slow switch to oral therapy
• Marketing pressure?
• Education-Training-Competency?
• Workload issues with poor attention to detail?
• Insufficient pharmacy involvement?

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http//id2.wustl.edu/casabar/downloads/antibiotic
stewardship08.pdf
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References

• Dellit TH, Owens RC, McGowan JE, et al.
  Infectious Diseases Society of America
• and the Society for Healthcare Epidemiology
  of America guidelines for
• developing an institutional program to
  enhance antimicrobial stewardship.
• Clin Infect Dis. 44 (1) 159-177, 2007.
• McQuillen DP, Petrak RM, Wasserman RB, et
  al. The value of infectious disease specialists
  Non-patient care activities. Clin Infect Dis.
  471051-1063, 2008.
• Spellberg B, Guidos R, Gilbert D, et al.
  The epidemic of antibiotic-resistant
• infections A call to action for the
  medical community from the Infectious
• Diseases Society of America. Clin Infect
  Dis. 46 (2) 155-164, 2008.

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Antimicrobial Stewardship

• QUESTIONS?