ANTIMICROBIAL STEWARDSHIP
PROJECT IN THE INTENSIVE CARE UNIT:
IMPACT ON QUALITY OF CARE AND
PATIENT SAFETY
Javier A. Adachi, MD
Department of Infectious Diseases, Infection Control & Employee Health
The University of Texas – M.D. Anderson Cancer Center
UT System Inaugural CS&E Conference, Austin
October 15, 2009
Multidisciplinary Antimicrobial
Stewardship Team (MAST) in ICU
• Team Core Members:
– Javier A. Adachi (ID, IC & EH)
– Roy Borchardt (ID, IC & EH)
– Roy F. Chemaly (ID, IC & EH)
– Victor E. Mulanovich (ID, IC & EH)
– Cheryl A. Perego (ID, IC & EH)
– S. Egbert Pravinkumar (CCM)
– Kenneth V.I. Rolston (ID, IC &EH)
•
– Coralia Mihu (ID, IC & EH)
– Bruno Granwehr (ID, IC & EH)
– Kathy Smith, Mary Mabry and Candice Scott (ID, IC & EH)
– Holly Hogan, Cynthia St. John, Karen Vigil and Souad Youssef
Facilitators:
– Issam Raad (ID, IC & EH)
– Kristen Price (CCM)
– Alma Rodriguez (VP, Medical Affairs)
MAST in ICU
• BACKGROUND:
• Worldwide, antimicrobial resistant has become a significant
problem, especially in cancer centers and ICU settings.
• Current relative dry pipeline for new antimicrobial agents
under development.
• Effective antimicrobial stewardship program:
– Allows better use of current available antimicrobial agents
– Decreases unnecessary antimicrobial use by 22%-36%
– Decreases length of hospital stay
– Decreases mortality rate and readmission rate
– Saves US$ 200,000-900,000 annually (in academic centers)
Clinical Infectious Diseases 2007; 44: 159-77
“Bad Bugs, No Drugs”, IDSA Advocacy Campaign
Clinical Infectious Diseases 2006; 657-68
MAST in ICU
•
•
•
•
Policy VII.A.1.101
Volume VII, Book A, Chapter, 03/30/2004
Restriction of Selected Antibiotics for Resistant Organisms
When indicated, empiric Vancomycin or Carbapenems use was
allowed for ≤ 7 days
• Vancomycin:
– Decreased use of vancomycin was associated with decreased
incidence of vancomycin resistant Enterococcus (VRE)
• Journal of Hospital Infection 2002; 51: 52-8
– MRSA and VRE infections are associated with
decreased survival, increased hospital stay and increased
attributable cost
• JAMA 1999; 282: 1745-51 & Clinical Infectious Diseases 2005; 41: 327-33
• Carbapenems (Meropenem & Imipenem Cilastatin):
– Use of carbapenems for ≥ 7 days was associated with multidrugresistant Pseudomonas (MDR-Ps) infection
• Cancer 2005; 104: 205-12
MAST in ICU
• STRATEGIES:
– Formulary restriction and preauthorization
(“front-end”)
– Prospective audit with intervention and
feedback (“back-end”)
Clinical Infectious Diseases 2007; 44: 159-77
100
11/1/05
11/705
11/14/05
11/21/05
11/28/05
12/5/05
12/12/05
12/19/05
12/25/05
1/30/06
2/6/06
2/13/06
2/20/06
2/27/06
3/6/06
3/13/06
3/20/06
3/27/06
6/26/06
7/3/06
7/10/06
7/17/06
7/24/06
7/31/06
8/7/06
8/14/06
8/21/06
8/28/06
11/1/06
11/6/06
11/13/06
11/20/06
11/27/06
12/4/06
12/11/06
12/18/06
12/25/06
Percent Compliant
Compliance with Judicious Use of Antimicrobials in ICU
MAST Pilot – CS&E 4: November’05 - December’06
NovDec Baseline
Compliance with Judicious Use of Antibiotics
FebMar-Initial
JulAug Pre-CS&E
Week
NovDec06-Focus
CL=92.169
88
75
LCL=73.171
63
50
38
25
13
0
Number of Patients with Non-Judicious Use of
Antibiotics in the ICU: Nov-Dec’05 & Nov-Dec’06
60
P
a
# t
i
o e
f n
t
s
57
50
40
30
20
10
13
0
November-December
2005
Cumulative Length of Stay
November-December
2006
Cost of Stay
$5,000,000
700
600
P
a
t
i
e
n
t
$4,500,000
$4,000,000
631
$4,524,901
$3,500,000
500
U $3,000,000
S
D
400
a
y 300
s
$2,500,000
$
$2,000,000
$1,500,000
200
$1,000,000
175
100
$1,254,925
$500,000
$0
0
November-December 2005
November-December 2006
ICU Bed Per Day=$7171 (FY07)
November-December 2005
November-December 2006
• AIM: To increase compliance of
judicious use of antimicrobials
(Vancomycin and Carbapenems) to
≥ 90% in Intensive Care Unit, from
November 2007 to December 2008
Figure 1: MAST PROJECT IN ICU
Cause and Effect Diagram (Fishbone Diagram)
Addressed by
MAST pilot project
Addressed by
current process
MAST in ICU
• Specific Objectives:
– Promote judicious use of vancomycin and
carbapenems in the ICU
– Evaluate patients on therapy with vancomycin or
carbapenems on day 5 for appropriate use
– Determine compliance with MAST recommendations
– The Multidisciplinary Antibiotic Stewardship Team
(MAST) independent from the ID consult service and
will not perform ID consultations
MAST in ICU
MAST IN ICU
100
0
11/1/05
11/21/05
12/12/05
1/30/06
2/20/06
3/13/06
6/26/06
7/17/06
8/7/06
8/28/06
11/13/06
12/4/06
12/25/06
1/4/08
1/25/08
2/18/08
3/10/08
3/31/08
4/21/08
5/12/08
6/02/08
6/25/08
7/18/08
8/9/08
9/1/08
9/22/08
10/13/08
11/3/07
11/24/08
12/15/08
Percent Compliant
MAST in ICU: Compliance with Judicious Use of Antimicrobials
2005
2006
2006
2006
2007 - 2008
Nov-Dec
Nov-Dec
Jul-Aug 0
Feb-MarJl-Au
No-DFe-M
No-D
Nov 07 - Dec 08
88
75
63
50
38
25
13
Week
UCL=100.000
CL=100.000
LCL=100.000
Incidence of Multidrug Resistant Pseudomonas
Hospital-Acquired Infections in ICU - FY07 to FY09* (Sep-Dec)
1.2
1.2
Incidence per 1000 patient days
1
0.85
0.8
0.59
0.6
0.37
0.4
0.28
0.22
0.22
0.16
FY07
0.2
0
FY08
FY09* (Sep-Dec'08)
0
Total ICU
FY07 vs FY08
p-value= 0.017
MICU
FY07 vs FY08
p-value= NS
SICU
FY07 vs FY08
p-value= 0.023
Mortality Associated with MDR-Pseudomonas
Hospital-Acquired Infections in ICU - FY07 to FY09* (Sep-Dec)
10
9
7
6
6
5
4
3
1
2
1
3
2
0
FY07
FY08
Survived Patients
1
FY09*
Expired Patients
% Deaths / Total ICU Discharges
# of Patients
8
16
14
12
13.39
10
10.84
8
6
4
2
0.18
0.03
0
FY07
FY08
MDR Pseudomonas Mortality Total ICU Mortality
Incidence of Vancomycin Resistant Enterococcus
Hospital-Acquired Infections in ICU - FY07 to FY09* (Sept-Dec)
Incidence per 1000 patient days
1.5
1.19
1
0.64
0.5
0.37
0.15
FY07
0.22
0.14
0.15
FY08
0.16
0
0
Total ICU
FY07 vs FY08
p-value= 0.054
MICU
SICU
FY07 vs FY08
p-value= 0.03
FY07 vs FY08
p-value= NS
FY09* (Sep-Dec'08)
Mortality Associated with VRE Hospital-Acquired
Infections in ICU - FY07 to FY09* (Sep-Dec)
10
9
# of Patients
8
7
6
7
5
4
3
2
1
1
2
1
1
FY08
FY09*
0
FY07
Survived Patients
Expired Patients
20
18
16
14
12
10
8
6
4
2
0
4.5
4.01
4
3.5
3
2.5
18
2
1.11
1.5
0.45
5
2
FY07
FY08
Number of Patients
2008 ICU Cost per Day=US$8224
1
0.5
0
FY09*
Cost (US$)
Average Cumulative Length of Stay=27.1 days
Millions of Dollars
# of Patients
Reduction in the Number of Patients and Cost of HospitalAcquired Resistant Infections in ICU – FY07 to FY09* (Sep-Dec)
MAST in ICU – Main Problems
•
•
•
•
Multidisciplinary
Open ICU model
Lack of electronic medical orders
Lack of real-time and adequate feedback
information
• Complicated process
• “Balloon effect”
– Other antimicrobials being used
• Non-revenue generating process
MAST in ICU – Conclusions
• An intense antimicrobial stewardship program, with
active enforcement from institutional leaders, would:
a) Result in more judicious use of antimicrobials in ICU
b) Decrease the rate of resistant infections in ICU
c) Correlate with reduction in the mortality associated with
resistant infections in ICU, and
d) Represent financial savings for the patients and the institution
• This MAST project in ICU has showed sustainability and
significant impact
• Next step: Gradually implement this program to cover all
inpatient and outpatient services in our comprehensive
cancer center. Department of Pharmacy should
participate as co-leaders in this project
Special Acknowledgements
•
•
•
•
•
•
Roy Borchardt
Roy Chemaly
Victor Mulanovich
Cheryl Perego
Egbert Pravinkumar
Kenneth Rolston
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Alma Rodriguez
Rebecca Arbuckle
Danielle Butler-Winey
Yvette de Jesus
Bruno Granwehr
Holly Hogan
Pauline Koinis
Mary Mabry
Coralia Mihu
• Faculty, Infection Control
Practitioners, Fellows,
Mid-level Providers, Clinical
Pharmacists and Supporting
Staff from the Office of the VP
of Medical Affairs and the
Departments of Critical Care
Medicine, Infectious Diseases/
Infection Control/Employee
Health and Pharmacy
Kim Nguyen
Kathy Smith
Cynthia St. John
Jeffrey Tarrand
Karen Vigil
Candice White
Souad Youssef
Thank You!
Any Questions?