Antimicrobial Stewardship
St. Mary’s Hospital
Infection Control Committee
What is Antimicrobial Stewardship
• An interdisciplinary team dedicated to
practices that improve appropriate selection,
dosing, route, and duration of antimicrobial
therapy
• The ultimate goal of antimicrobial stewardship
is to improve patient care and health care
outcomes
Antimicrobial Stewardship Team
•
•
•
•
Infectious Disease Physician
Clinical Pharmacist
Clinical microbiologist
Information System
Specialist
• Infection control
professional
• Hospital epidemiologist
• Leadership support
Elements of an Antimicrobial
Stewardship Team
• A comprehensive program will include:
– Active monitoring of resistance
– Fostering of appropriate antimicrobial use
– Collaboration with an effective infection control
program to minimize secondary spread of
resistance is considered optimal
Elements of an Antimicrobial
Education
Stewardship• Program
• Prospective audit with
intervention and feedback
• Formulary restriction and
preauthorization
• Guidelines and clinical
pathways
• Antimicrobial cycling
• Antimicrobial Order Forms
• Monitoring of progress and
outcome measures
• De-escalation of therapy
• Dose optimization
• Conversion from parenteral
to oral
• Computer
Surveillance/Decision
Support
• Microbiology Laboratory
Prospective audit,intervention,and
feedback
• Have the clinical
pharmacist on the floor
making
recommendations
about appropriate
antibiotic, route, length
of therapy
• Probiotic Protocol to
prevent C. Diff
• Focus on one floor for
recommendations
• Up to a 37% reduction in the
number of days of
inappropriate antibiotic
use.Approx. $400.00 cost
savings per patient
• While assessing patients for
probiotics look at deescalating of antibiotics
• Decrease rate of C. Diff
Formulary restriction and preauthorization
• Restriction
of
requirements for specific
agents
• Control of certain antibiotic
use through Pharmacy and
Therapeutics Committee can
be very effective
• Control of Cleocin use has
led to prompt cessation of
nosocomial outbreak of C.
Diff
Vancomycin and third
generation
cephalosporins in
response to VRE has
demonstrated mixed
results
Education
•
•
•
•
Conference Presentations
Student teaching
E-mail alerts
Provision of written
guidelines
• Peri-operative area order
forms
• Share results of audits
Guidelines and Clinical Pathways
• Implementation of guidelines
incorporating local microbiology
and resistance patterns
• Balance antibiotics in HAP and
VAP patients
• Use algorithms incorporating the
clinical pulmonary infection score
• Leads to decreased duration of
therapy,decreased VAP
recurrence, decrease of multidrug resistance patterns
Antimicrobial Cycling
• Slows spread of
resistance
• Most popular is
Gentamicin to Amikacin
• Ceftazadime for
Ciprofloxacin lead to a
decreased incidence of
VAP
Antimicrobial Order Forms
• Use of Peri-operative
prophylactic order forms
with automatic stop at 2
days (SCIP Guidelines)
• Pneumonia Order set
(Pneumonia core measures)
with 6 different pneumonia
indications and drugs
• Order forms facilitate
implementation of practice
guidelines
Streamlining or De-Escalation of therapy
• Continuing excessive broad therapy contributes to the
selection of antimicrobial resistant pathogens
• When culture results become available we can streamline or
de-escalate antimicrobial therapy to more targeted therapy
that decreases antimicrobial exposure and contains cost
• This can also lead to avoidance of redundant inpatient
antibiotic- days
Dose Optimization
• Dosing that accounts for
individual patient
characteristics
(age,weight,renal function)
• Site of infection
• Pharmacokinetics Vancomycin and
aminoglycosides
• Optimize antimicrobial
pharmacodynamics of the
drugs B-lactams and
fluoroquinolones
Conversion from parenteral to oral
therapy
• Having a systematic plan for
switching from parenteral to
oral treatment may have an
added benefit of aiding in
early hospital discharge
planning
• Development of clinical
criteria and guidelines
allowing conversion can
facilitate implementation.
Computer Surveillance / Microbiology
• Add cost codes to
antimicrobial susceptibility
data
• Antimicrobial report to
pharmacy
• Vancomycin
dosing/utilization sheet
• Review antimicrobial errors
• Leap frog to CPOE
• Actively involved in
resistance surveillance
• Update antibiogram
annually
• Make easily accessible
to physicians
St.Mary’s Antibiotic Stewardship
Efforts to Date
•
•
•
•
•
•
•
•
Probiotic Protocol
Antibiogram on line
Pneumonia Order sets
Pharmacokinetics
Peri-op Area Guidelines
IV to PO conversion
Culture results from lab
Pharmacy/IS generated
pneumonia vaccine program
What does our future hold for Antibiotic
Stewardship
• Assign antibiotic rounds to
new pharmacy school
professor ( de-escalating
and streamlining)
• Follow culture results from
lab
• Approve IV to PO conversion
automatic by pharmacist
• Finish 6 month Probiotic
study
• Work on Vancomycin Order
form
Antibiotic Stewardship 2013
140
18.5
120
18
100
17.5
80
60
17
40
16.5
20
0
-1
4
N
ov
p-
14
4
Se
l-1
Ju
14
ay
-
4
M
ar
-1
M
Ja
n-
14
16
#Interventions
% Acceptance
15.5
1stQtr 2ndQtr 3rd Qtr 4th Qtr
TARGET
Athens cost per discharge
Total Savings 2013 $15,458
Documentation of Interventions by type
MONTH : SEPTEMBER 2013
Total Antibiotic Interventions:100
Percent Accepted: 85%
Accepted
Change
Dose
Change
Antibiotic
IV to PO
conversion
Discontinue
Therapy
Add an
antibiotic
Renal
dosing
Streamline
1
10
21
28
1
15
2
8
5
6
3
1
15
27
31
2
15
2
8
Not
accepted
Total
1
•
April Ecker and Gin Fleming (Antibiotic Pharmacist)
Other:
Probiotic
C.H.E. Act Initiatives Thru September 2013
Anti-infectives
(Antibiotics)
Anticoagulants
25
20
7
2011-2013 Target
6
5
15
Cost per
adjusted
discharge
10
5
0
Anticoag cost per
adjusted discharge
3
2
1
3
l-1
13
Mar- Apr- M Jun- JulA Sep- Oct13
13 ay13
13 ug- 13
13
13
13
Ju
2
Ja
n-
12
l-1
Ju
Ja
n-
l-1
1
11
0
Ju
Ja
n-
Target
4
Asthma Drugs
1
9
8
Proton Pump
Inhibitors
0.95
7
0.9
6
Target
5
Asthma Drugs Cost per
adjusted discharge
4
3
TARGET
0.85
PPI COST PER ADJUSTED
DISCHARGE
0.8
2
0.75
1
0
12
N
ov
-1
2
Ja
n13
M
ar
-1
3
M
ay
-1
3
Ju
l-1
3
Se
p13
Se
p-
-1
2
Ju
l
12
M
ay
-
M
ar
-
12
0.7
Mar13
Apr13
May- Jun13
13
Jul13
Aug- Sep13
13
Oct13
ACT-Medication Management
Anti-Infective Stewardship Initiative
2010
$30.00
$25.00
2010 Target
$20.00
$15.00
$10.00
$5.00
Ja
nFe 1 0
bM 10
ar
-1
A 0
pr
M 10
ay
-1
Ju 0
nJu 10
ly
20
A 1
ug
Se 10
p1
O 0
ct
N 10
ov
-1
0
$0.00
Cost per adjusted
discharge
St. Mary's 2010
Target