Antimicrobial Stewardship
Jeffrey S. Gerber, MD, PhD
Assistant Professor of Pediatrics
University of Pennsylvania School of Medicine
Division of Infectious Diseases
The Children’s Hospital of Philadelphia
Topics
• The case for Antimicrobial Stewardship
• Define and Discuss Data for ASPs
• Examples of Stewardship
Magnitude of Antibiotic Use
• antibiotics are the second most commonly used
class of drugs in the US ($8 billion/yr)
• 60% of children admitted to freestanding
children’s hospitals receive antibiotics
• 50% of antibiotic use is inappropriate
Anti-infective use in US Hospitals
Hoffman et al. Am J Health Syst Pharm. 2012 Mar 1;69(5):405-21
Total outpatient antibacterial use in the United States and 27 European countries in 2004
(total use for Greece, Iceland, and Bulgaria, 2002 data for Poland, and 2003 data for Italy).
Goossens H et al. Clin Infect Dis. 2007;44:1091-1095
© 2007 Infectious Diseases Society of America
Top 1 through 6 drug markets according to the total estimated number of outpatient
prescriptions dispensed to the US pediatric population (ages 0–17 years) from US retail
pharmacies, 2002 through 2010. *Statistically significant linear trend at P value = .05.
Chai G et al. Pediatrics 2012;130:23-31
©2012 by American Academy of Pediatrics
Adverse effects of Antibiotic use
• antibiotics are the most common cause of ED
visits for adverse drug events in children
• use drives resistance
• antibiotic-resistant infections:
– $20 billion in excess healthcare costs
– $35 billion in societal costs
– 8 million additional hospital days
Antibiotic Resistance
Antibiotic Resistance
• CDC described antibiotic resistance as "one of the
world's most pressing health problems”
• the WHO has identified antibiotic resistance as "one
of the three greatest threats to human health."
Resistance Aside …
• 5%–25% diarrhea
• 1 in 1000 visit emergency department for
adverse effect of antibiotic
– comparable to insulin, warfarin, and digoxin
• 1 in 4000 chance that an antibiotic will
prevent serious complication from URI
Shehab N. CID 2008:47; Linder JA. CID 2008:47
A, Proportion of subjects developing IBD according to age and antianaerobic antibiotic
exposure status.
Kronman M P et al. Pediatrics 2012;130:e794-e803
©2012 by American Academy of Pediatrics
Antibiotics in early life alter the murine
colonic microbiome and adiposity
• Mice fed subtherapeutic doses of antibiotics exhibited:
– Increased adiposity
– Increased hormone levels related to metabolism
– Taxonomic changes of microbiome
– Changes in copies of key genes involved in
metabolism of carbohydrates to short-chain fatty
acids
– Alterations in hepatic metabolism of lipids and
cholesterol
– Increase in colonic levels of short chain fatty acids
Cho I et al. Nature 2012
Topics
• The case for Antimicrobial Stewardship
• Define and Discuss Data for ASPs
• Examples of Stewardship
Antimicrobial Stewardship: Definition
• “optimal selection, dosage, and duration
of antimicrobial treatment that results in
the best clinical outcome for the treatment
or prevention of infection with minimal
toxicity to the patient and minimal impact
on subsequent resistance”
Owens RC, Pharmacotherapy 2004
Antimicrobial Stewardship
ASP
• a quality improvement initiative proven in
multiple, peer-reviewed studies to:
• improve patient outcomes
• shorten length of stay
• reduce Clostridium difficile infection rates
• reduce antimicrobial resistance
• save money
Antimicrobial Stewardship
ASP
• recommended by: CDC, IDSA, SIS, AAP, PIDS
Key Elements for Successful ASP
•
•
•
•
establish compelling need and goals
senior leadership support
effective local physician champion
adequate resources
–
–
–
–
pharmacy
infection prevention & control
clinical labs (microbiology/virology)
information technology
• agreed upon process and outcome measures
Principles of Judicious Antimicrobial Use
•
•
•
•
•
evidence based empiric tx
early/aggressive tx
narrow when organism isolated
stop if infection unlikely
limit duration for established infections
based upon current evidence
Antibiotic Strategies to Reduce
Antibiotic Resistance
• Blast them: use > 1 antimicrobial to prevent the
emergence of resistance
• Fool them
– Antibiotic cycling or rotation
– Multi-drug resistance and ability of antibiotics to cross
select resistance
• Stop irritating them – reduce our antibiotic use to the
bare minimum necessary to safely treat our patients
Rice LB. CID 2008
Shorter Durations of Therapy
• Knowledge about duration of therapy limited
• Traveler’s diarrhea: recommendation is for 3
days (but 1 d appears equally effective)
• UTI in young females: 1-3 days
• Community-acquired pneumonia
– “Minimum of 5 days, afebrile for 48-72
hours, clinically stable
• Intra-abdominal infection
• 5-7 days
Rice LB, CID 2008
ASP Improves Clinical Outcomes
RR 2.8 (95% CI 2.1-3.8)
RR 1.7 (95% CI 1.3-2.1)
RR 0.2 (95% CI 0.1-0.4)
Fishman N. Am J Med. 2006;119(6 suppl 1):S53-S61.
ASP Saves Money
• Annual savings (600 interventions/month)
– Antibiotics:
$302,400.00
– Infx-assoc costs: $533,000.00
– Total costs:
$4,277,000.00
RR 2.8 (95% CI 2.1-3.8)
RR 1.7 (95% CI 1.3-2.1)
RR 0.2 (95% CI 0.1-0.4)
Fishman N. Am J Med. 2006;119(6 suppl 1):S53-S61.
Depicts the logistics of the prospective-audit-with-feedback antimicrobial stewardship
program developed and implemented at Children's Mercy Hospitals and Clinics.
Stach L M et al. J Ped Infect Dis 2012;1:190-197
© The Author 2012. Published by Oxford University Press on behalf of the Pediatric Infectious
Diseases Society. All rights reserved. For Permissions, please e-mail:
journals.permissions@oup.com
Positive and negative feelings of clinicians regarding the antimicrobial stewardship program.
Stach L M et al. J Ped Infect Dis 2012;1:190-197
© The Author 2012. Published by Oxford University Press on behalf of the Pediatric Infectious
Diseases Society. All rights reserved. For Permissions, please e-mail:
journals.permissions@oup.com
Perceived Barriers to Implementation,
Development and Improvement of an
Antimicrobial Stewardship Program (ASP)
No. (%) of respondents
Barrier
With
Current ASP
(n=45)
Planning
ASP
(n=25)
No plans
For ASP
(n=68)
Any*
36 (80)
25 (100)
59 (87)
Loss of prescriber autonomy
14 (31)
14 (56)
23 (34)
Lack of funding*
14 (31)
18 (72)
35 (51)
Lack of time*
16 (36)
17 (68)
36 (53)
Administration not aware of ASP value
10 (22)
10 (40)
17 (25)
*p < .05.
Hersh A et al, ICHE 2009
Topics
• Define and discuss rationale for ASP
• Describe the CHOP ASP
• Special Applications
– pediatric surgery
– primary care
ASP-EPIC Workflow
Pathways, Safety-Net
HAI, Influenza
clinical resource
Infection
Prevention &
Control
Pandemic Influenza
Clinical resource
Office of Patient
Safety & Quality
Division of
Infectious
Diseases
Emergency
Preparedness
ASP support/consultation
education, ASP-Epic workflow
CHOP
ASP
Divisions &
Departments &
Hospital
antibiotic DUE, formulary,
clinical resource,
assist in drug shortages
Department
of
Pharmacy
Services
Residents,
Fellows, &
Nursing
Division-specific
pathways and
guidelines;
Operating Plan
Initiatives (HAI)
clinical guidelines;
content experts/support
Microbiology
& Virology
antibiogram, clinical resource
antimicrobials, & antivirals
Vascular
Access Service
clinical resource,
lock therapy, damaged
CVC CLABSI
CHOP ASP: Driver Diagram
guideline development
Timely and appropriate
initiation of antibiotics
clinical pathways
clinical decision support?
formulary restriction
Optimize
antimicrobial
use
Appropriate administration
& de-escalation of therapy
clinical pharmacy
clinical microbiology lab
IV  PO conversion
EPIC and PHIS reports
Data monitoring
and transparency
routine data audits
CHOP antibiogram
clinician feedback?
outcomes:
-adherence to guidelines
-benchmark comparison
-bug/drug mismatch rate
-antibiogram shift
-antimicrobial costs
Improving ASP infrastructure,
knowledge, and engagement
support of administration
education and outreach
optimize EPIC interface
literature review, research,
national ASP meetings
CHOP ASP: 2012
• 1.5 months
• 55% received intervention:
Stop (10%)
Optimize regimen
(32%)
ID consult
(24%)
ASP Advice
(34%)
CLABSI: Tx compliance
= at or above target
= within 15% of Target
= >15% from Target
EMPIRIC TX
DEFINITIVE TX
DURATION of TX
PATHOGEN TARGETED
= at or above target
= within 15% of Target
= >15% from Target
BSI
PATHOGEN TARGETED: HA
1.2
1
0.8
0.6
EMPIRIC TX
0.4
0.2
1.2
0
1
FY1
1 Q1
FY1
1 Q2
FY1
1 Q3
FY1
1 Q4
0.8
% Appropriate
0.75
1
1
0.67
0.6
Target
0.9
0.9
0.9
0.9
FY1
2 Q1
0.9
FY1
2 Q2
FY1
2 Q3
1
1
0.9
0.9
0.4
PATHOGEN TARGETED: CA
0.2
0
% Appropriate
Target
FY12Q1
FY12Q2
FY12Q3
1
1
1
0.9
0.9
0.9
1.2
1
0.8
0.6
0.4
0.2
0
% Appropriate
Target
FY11Q FY11Q FY11Q FY11Q FY12Q FY12Q FY12Q
1
2
3
4
1
2
3
1
0.95
1
0.97
1
1
0.9
0.9
0.9
0.9
0.9
0.9
0.9
0.9
Cost Savings: $714,463
$600,000.00
$547,942.50
$500,000.00
$400,000.00
$300,000.00
$200,000.00
$139,152.00
$100,000.00
$21,701.00
$-
Pharmacy subgroup including ASP - Supply Chain Cost Revision team FY10
$5,667.63
Topics
• The case for Antimicrobial Stewardship
• Define and Discuss Data for ASPs
• Examples of Stewardship: MEASUREMENT
How do we Benchmark use?
PHIS Hospitals
Minnesota
Omaha
Kansas City
Milwaukee
Dayton
Chicago
Columbus
St. Louis
Cincinnati
Detroit
Akron
Indianapolis
Buffalo
Boston
Hartford
New York
Philadelphia
Seattle
DC
Oakland
Norfolk
Pittsburgh
Palo Alto
Phoenix
Memphis
Madera
Denver
Nashville
Los Angeles
Dallas
Little Rock
Atlanta
Orange
Fort Worth
New Orleans
St. Petersburg
San Diego
Corpus Christi
Birmingham
Miami
Houston
Benchmarking Antibiotic Use: CHA Hospitals
Gerber et al. Pediatrics 2010
Antibiotic Use at Children’s Hospitals,
by Service Line
Percent of Total Abx Use
(524,364 discharges from 32 hospitals in 2010)
0%
5%
10%
15%
20%
25%
Surgery
22.3%
Pulmonary
9.2%
Neonatology
5.9%
Hematology
4.2%
Oncology
3.7%
Gastroenterology
2.8%
Other
2.7%
Bone Marrow Transplant
2.6%
Cardiology
35%
40%
45%
40.8%
Infectious Diseases
Neurology
30%
1.5%
1.0%
Orthopedics/Rheumatology
0.6%
Urology/Nephrology
0.6%
Dermatology
0.5%
Endocrine/Metabolism
0.4%
ENT
0.4%
Dental
0.3%
Psychiatry
0.3%
Ophthalmology
0.2%
Rehab
0.2%
HIV
0.0%
OBGYN
0.0%
Variability of Antibiotic Use Across Hospitals, Top Four APR-DRGs
Each circle represents one hospital. Size of circles corresponds to number of discharges with diagnosis receiving antibiotics. Red lines represent median values.
Broad-spectrum anti-MRSA coverage: vancomycin, linezolid, tigecycline, daptomycin
Broad-spectrum anti-pseudomonal coverage: imipenem, meropenem, cefepime, piperacillin, ticarcillin, piperacillin-tazobactam, ticarcillin-clavulanate, ceftazidime
CHOP ASP: Intranet Site
Implementation of a CAP Guideline
Newman RE et al. Pediatrics 2012
Topics
• The case for Antimicrobial Stewardship
• Define and Discuss Data for ASPs
• Examples of Stewardship: SURGERY
Antibiotic Use at Children’s Hospitals,
by Service Line
Percent of Total Abx Use
(524,364 discharges from 32 hospitals in 2010)
0%
5%
10%
15%
20%
25%
Surgery
22.3%
Pulmonary
9.2%
Neonatology
5.9%
Hematology
4.2%
Oncology
3.7%
Gastroenterology
2.8%
Other
2.7%
Bone Marrow Transplant
2.6%
Cardiology
35%
40%
45%
40.8%
Infectious Diseases
Neurology
30%
1.5%
1.0%
Orthopedics/Rheumatology
0.6%
Urology/Nephrology
0.6%
Dermatology
0.5%
Endocrine/Metabolism
0.4%
ENT
0.4%
Dental
0.3%
Psychiatry
0.3%
Ophthalmology
0.2%
Rehab
0.2%
HIV
0.0%
OBGYN
0.0%
Surgical Antimicrobial Prophylaxis
• surgical AMP is used to reduce the
microbial burden of skin colonization
that may contribute to intraoperative
contamination
• 2nd most common Healthcare
Associated Infection (HAI)
• SSIs cause harm, prolong
hospitalizations, can cause
readmissions, and can increases
mortality rate
• Prophylaxis; not treatment
When appropriately used, AMP
reduces SSI rate by 50-70%
Prevent SSI: Driver Diagram
home baths (+/- CHG)
skin colonization
identify MRSA (MDRO)
PREoperative
choice of antiseptic
skin colonization
periop antibiotics
approp. hair removal
Prevent
Surgical Site
Infections
INTRAoperative
environment
room traffic
surgical technique
physiology
temperature/glucose
hand hygiene
wound care
dressing changes
POSToperative
physiology
wound assessment
temperature/glucose
Surgical Wound Classes
I. Clean: An uninfected operative wound in which no
inflammation is encountered and the respiratory, alimentary,
genital, or uninfected urinary tracts are not entered
II. Clean-Contaminated: Operative wounds in which the
respiratory, alimentary, genital, or urinary tracts are entered
under controlled conditions and without unusual contamination
III. Contaminated: Open, fresh, accidental wounds;
operations with major breaks in sterile technique or gross
spillage from GI tract, and incisions in which acute, nonpurulent
inflammation is encountered
IV. Dirty or Infected: Includes old traumatic wounds with
retained devitalized tissue and those that involve existing clinical
infection or perforated viscera
Antimicrobial Prophylaxis: Timing
Goal is to have peak antibiotic
serum/tissue levels at the time of
incision.
Therefore, complete antibiotic infusion
0 - 60 minutes prior to incision
 Start 0-60 minutes prior to
incision for agents with brief
infusion times
 Start 60-120 minutes prior to
incision for vancomycin and
fluoroquinolones
For longer procedures or with
excessive blood loss, antibiotic(s)
may require intraop re-dosing
Antimicrobial Choice
Staphylococcus aureus is most common cause of SSI
Cefazolin has activity against most strains of S.
aureus; therefore, Cefazolin is the empiric choice for
most procedures
However, Cefazolin may not always be the appropriate
choice…
1. procedures involving organs with alternate or
additional colonizing bacteria (e.g. GI tract)
2. patients with cephalosporin allergy
3. patients known to be colonized with resistant
bacteria
Antimicrobial Selection:
Using CHOP Guidelines
Surgery
Antibiotic
Alternative for Penicillin
and/or Cephalosporin
allergy
MRSA
History of colonization or infection
Cardiothoracic
Recommendations for choice,
timing, dose, and re-dose timing of
AMP for children are available on
CHOP intranet and in all ORs
http://intranet.chop.edu/sites/anti
microbial/periop-antibioticprophylaxis.html
General
cefazolin
clindamycin
vancomycin1 + cefazolin
High-risk implants
(pacemaker, ICD, LVAD)
vancomycin +
cefazolin
vancomycin + gentamicin
vancomycin1+ cefazolin
Lung transplant
targeted therapy2
targeted therapy2
vancomycin1+ targeted therapy2
Appendectomy3
ceftriaxone +
metronidazole
ciprofloxacin +
metronidazole
vancomycin1 + ceftriaxone +
metronidazole
Esophageal,
gastroduodenal,
jejunal
cefazolin
clindamycin + gentamicin
vancomycin1 + cefazolin
Colorectal3
ceftriaxone and
metronidazole
ciprofloxacin +
metronidazole
vancomycin1+ ceftriaxone +
metronidazole
Liver transplant
piperacillin/tazobac
tam
ciprofloxacin +
metronidazole
vancomycin1 + piperacillin/tazobactam
NEC
piperacillin/tazobac
tam
none
vancomycin1 + piperacillin/tazobactam
cefazolin
clindamycin + gentamicin
vancomycin1+ cefazolin
Clean
none
none
none
With implant
cefazolin
clindamycin + gentamicin
vancomycin1 + cefazolin
Clean-contaminated
cefazolin
clindamycin + gentamicin
vancomycin1 + cefazolin
cefazolin or
cefoxitin
clindamycin + gentamicin
vancomycin1 + cefazolin
General
cefazolin
clindamycin
vancomycin1+ cefazolin
High-risk implants
(spinal rods, VEPTR)
vancomycin +
cefazolin (+/gentamicin) 4
vancomycin + gentamicin
Vancomycin1+ cefazolin
(+/- gentamicin) 4
cefazolin
vancomycin
vancomycin1 + cefazolin
General
cefazolin
clindamycin + gentamicin
vancomycin1 + cefazolin
Cystourethroscopy
targeted therapy5
targeted therapy5
vancomycin1 + targeted therapy5
Gastrointestinal
Biliary tract
Open and
laparoscopic
procedures
Head and Neck
Obstetric or Gynecologic
Please call the CHOP
Antimicrobial Stewardship
Program, pager 10201, with
any questions
Cesarean section
Orthopedic
Neurosurgery
Urologic
Antimicrobial Selection:
Using CHOP Guidelines
Surgery
Antibiotic
Alternative for Penicillin
and/or Cephalosporin
allergy
MRSA
History of colonization or infection
Cardiothoracic
General
cefazolin
clindamycin
vancomycin1 + cefazolin
High-risk implants
(pacemaker, ICD, LVAD)
vancomycin +
cefazolin
vancomycin + gentamicin
vancomycin1+ cefazolin
Lung transplant
targeted therapy2
targeted therapy2
vancomycin1+ targeted therapy2
Appendectomy3
ceftriaxone +
metronidazole
ciprofloxacin +
metronidazole
vancomycin1 + ceftriaxone +
metronidazole
Esophageal,
gastroduodenal,
jejunal
cefazolin
clindamycin + gentamicin
vancomycin1 + cefazolin
Colorectal3
ceftriaxone and
metronidazole
ciprofloxacin +
metronidazole
vancomycin1+ ceftriaxone +
metronidazole
Liver transplant
piperacillin/tazobac
tam
ciprofloxacin +
metronidazole
vancomycin1 + piperacillin/tazobactam
NEC
piperacillin/tazobac
tam
none
vancomycin1 + piperacillin/tazobactam
cefazolin
clindamycin + gentamicin
vancomycin1+ cefazolin
Clean
none
none
none
With implant
cefazolin
clindamycin + gentamicin
vancomycin1 + cefazolin
Clean-contaminated
cefazolin
clindamycin + gentamicin
vancomycin1 + cefazolin
cefazolin or
cefoxitin
clindamycin + gentamicin
vancomycin1 + cefazolin
General
cefazolin
clindamycin
vancomycin1+ cefazolin
High-risk implants
(spinal rods, VEPTR)
vancomycin +
cefazolin (+/gentamicin) 4
vancomycin + gentamicin
Vancomycin1+ cefazolin
(+/- gentamicin) 4
cefazolin
vancomycin
vancomycin1 + cefazolin
General
cefazolin
clindamycin + gentamicin
vancomycin1 + cefazolin
Cystourethroscopy
targeted therapy5
targeted therapy5
vancomycin1 + targeted therapy5
Gastrointestinal
1) procedures involving
organs with alternate or
additional colonizing
bacteria
Biliary tract
Open and
laparoscopic
procedures
Head and Neck
Obstetric or Gynecologic
Cesarean section
Orthopedic
Neurosurgery
Urologic
Antimicrobial Selection:
Using CHOP Guidelines
Surgery
Antibiotic
Alternative for Penicillin
and/or Cephalosporin
allergy
MRSA
History of colonization or infection
Cardiothoracic
General
cefazolin
clindamycin
vancomycin1 + cefazolin
High-risk implants
(pacemaker, ICD, LVAD)
vancomycin +
cefazolin
vancomycin + gentamicin
vancomycin1+ cefazolin
Lung transplant
targeted therapy2
targeted therapy2
vancomycin1+ targeted therapy2
Appendectomy3
ceftriaxone +
metronidazole
ciprofloxacin +
metronidazole
vancomycin1 + ceftriaxone +
metronidazole
Esophageal,
gastroduodenal,
jejunal
cefazolin
clindamycin + gentamicin
vancomycin1 + cefazolin
Colorectal3
ceftriaxone and
metronidazole
ciprofloxacin +
metronidazole
vancomycin1+ ceftriaxone +
metronidazole
Liver transplant
piperacillin/tazobac
tam
ciprofloxacin +
metronidazole
vancomycin1 + piperacillin/tazobactam
NEC
piperacillin/tazobac
tam
none
vancomycin1 + piperacillin/tazobactam
cefazolin
clindamycin + gentamicin
vancomycin1+ cefazolin
Clean
none
none
none
With implant
cefazolin
clindamycin + gentamicin
vancomycin1 + cefazolin
Clean-contaminated
cefazolin
clindamycin + gentamicin
vancomycin1 + cefazolin
cefazolin or
cefoxitin
clindamycin + gentamicin
vancomycin1 + cefazolin
General
cefazolin
clindamycin
vancomycin1+ cefazolin
High-risk implants
(spinal rods, VEPTR)
vancomycin +
cefazolin (+/gentamicin) 4
vancomycin + gentamicin
Vancomycin1+ cefazolin
(+/- gentamicin) 4
cefazolin
vancomycin
vancomycin1 + cefazolin
General
cefazolin
clindamycin + gentamicin
vancomycin1 + cefazolin
Cystourethroscopy
targeted therapy5
targeted therapy5
vancomycin1 + targeted therapy5
Gastrointestinal
1) procedures involving
organs with alternate or
additional colonizing
bacteria
2) patients with
cephalosporin allergy
Biliary tract
Open and
laparoscopic
procedures
Head and Neck
Obstetric or Gynecologic
Cesarean section
Orthopedic
Neurosurgery
Urologic
Antimicrobial Selection:
Using CHOP Guidelines
Surgery
Antibiotic
Alternative for Penicillin
and/or Cephalosporin
allergy
MRSA
History of colonization or infection
Cardiothoracic
General
cefazolin
clindamycin
vancomycin1 + cefazolin
High-risk implants
(pacemaker, ICD, LVAD)
vancomycin +
cefazolin
vancomycin + gentamicin
vancomycin1+ cefazolin
Lung transplant
targeted therapy2
targeted therapy2
vancomycin1+ targeted therapy2
Appendectomy3
ceftriaxone +
metronidazole
ciprofloxacin +
metronidazole
vancomycin1 + ceftriaxone +
metronidazole
Esophageal,
gastroduodenal,
jejunal
cefazolin
clindamycin + gentamicin
vancomycin1 + cefazolin
Colorectal3
ceftriaxone and
metronidazole
ciprofloxacin +
metronidazole
vancomycin1+ ceftriaxone +
metronidazole
Liver transplant
piperacillin/tazobac
tam
ciprofloxacin +
metronidazole
vancomycin1 + piperacillin/tazobactam
NEC
piperacillin/tazobac
tam
none
vancomycin1 + piperacillin/tazobactam
cefazolin
clindamycin + gentamicin
vancomycin1+ cefazolin
Clean
none
none
none
With implant
cefazolin
clindamycin + gentamicin
vancomycin1 + cefazolin
Clean-contaminated
cefazolin
clindamycin + gentamicin
vancomycin1 + cefazolin
cefazolin or
cefoxitin
clindamycin + gentamicin
vancomycin1 + cefazolin
General
cefazolin
clindamycin
vancomycin1+ cefazolin
High-risk implants
(spinal rods, VEPTR)
vancomycin +
cefazolin (+/gentamicin) 4
vancomycin + gentamicin
Vancomycin1+ cefazolin
(+/- gentamicin) 4
cefazolin
vancomycin
vancomycin1 + cefazolin
General
cefazolin
clindamycin + gentamicin
vancomycin1 + cefazolin
Cystourethroscopy
targeted therapy5
targeted therapy5
vancomycin1 + targeted therapy5
Gastrointestinal
1) procedures involving
organs with alternate or
additional colonizing
bacteria
2) patients with
cephalosporin allergy
3) colonization with resistant
bacteria
specific procedures
MRSA colonization
Biliary tract
Open and
laparoscopic
procedures
Head and Neck
Obstetric or Gynecologic
Cesarean section
Orthopedic
Neurosurgery
Urologic
Antimicrobial Selection:
Using CHOP Guidelines
Surgery
Antibiotic
Alternative for Penicillin
and/or Cephalosporin
allergy
MRSA
History of colonization or infection
Cardiothoracic
General
cefazolin
clindamycin
vancomycin1 + cefazolin
High-risk implants
(pacemaker, ICD, LVAD)
vancomycin +
cefazolin
vancomycin + gentamicin
vancomycin1+ cefazolin
Lung transplant
targeted therapy2
targeted therapy2
vancomycin1+ targeted therapy2
Appendectomy3
ceftriaxone +
metronidazole
ciprofloxacin +
metronidazole
vancomycin1 + ceftriaxone +
metronidazole
Esophageal,
gastroduodenal,
jejunal
cefazolin
clindamycin + gentamicin
vancomycin1 + cefazolin
Colorectal3
ceftriaxone and
metronidazole
ciprofloxacin +
metronidazole
vancomycin1+ ceftriaxone +
metronidazole
Liver transplant
piperacillin/tazobac
tam
ciprofloxacin +
metronidazole
vancomycin1 + piperacillin/tazobactam
NEC
piperacillin/tazobac
tam
none
vancomycin1 + piperacillin/tazobactam
cefazolin
clindamycin + gentamicin
vancomycin1+ cefazolin
Clean
none
none
none
With implant
cefazolin
clindamycin + gentamicin
vancomycin1 + cefazolin
Clean-contaminated
cefazolin
clindamycin + gentamicin
vancomycin1 + cefazolin
cefazolin or
cefoxitin
clindamycin + gentamicin
vancomycin1 + cefazolin
General
cefazolin
clindamycin
vancomycin1+ cefazolin
High-risk implants
(spinal rods, VEPTR)
vancomycin +
cefazolin (+/gentamicin) 4
vancomycin + gentamicin
Vancomycin1+ cefazolin
(+/- gentamicin) 4
cefazolin
vancomycin
vancomycin1 + cefazolin
General
cefazolin
clindamycin + gentamicin
vancomycin1 + cefazolin
Cystourethroscopy
targeted therapy5
targeted therapy5
vancomycin1 + targeted therapy5
Gastrointestinal
1) procedures involving
organs with alternate or
additional colonizing
bacteria
2) patients with
cephalosporin allergy
3) colonization with resistant
bacteria
specific procedures
MRSA colonization
Biliary tract
Open and
laparoscopic
procedures
Head and Neck
Obstetric or Gynecologic
Cesarean section
Orthopedic
Neurosurgery
Urologic
How do we do at CHOP?
Orhtopedic Surgery
n=175 for antibiotics
Cardiac Surgery
n = 48 for antibiotic
Abx Not
Administered
3%
Appropriate
Abx Admin
100%
Appropriate
Abx Admin
97%
Intra-abdominal Infections
Intra-abdominal Infections
intra-abdominal infection
communityacquired
mildmoderate
Ceftriaxone + metronidazole
healthcareacquired
SEVERE
any severity
piperacillin & tazobactam
ALT: ciprofloxacin + metronidazole
Intra-abdominal Infections: duration
• antimicrobial tx of established infection should
be limited to 4–7 days, unless difficult to
achieve adequate source control
Intra-abdominal Infections: prophylaxis
• acute appendicitis without evidence of
perforation, abscess, or local peritonitis requires
only prophylactic administration of narrow
spectrum regimens; treatment should be
discontinued within 24h
Topics
• The case for Antimicrobial Stewardship
• Define and Discuss Data for ASPs
• Examples of Stewardship: PRIMARY CARE
Antimicrobial Stewardship
• Antimicrobial Stewardship Programs
recommended for hospitals
• most antibiotic use (and misuse) occurs in
the outpatient setting
• is outpatient “stewardship” achievable?
Study Setting: CHOP Care Network
•5 urban, academic
•24 “private” practices
urban, suburban,
rural
•common EHR
Antibiotic Prescribing for Sick Visits
Excluding: preventive visits, CCC
Standardized by: age, sex, age-sex, race, Medicaid
Broad Antibiotic Prescribing
Excluding: preventive visits, CCC, antibiotic allergy, prior antibiotics
Standardized by: age, sex, age-sex, race, Medicaid
Broad Antibiotics for Sinusitis
Excluding: preventive visits, CCC, antibiotic allergy, prior antibiotics
Standardized by: age, sex, age-sex, race, Medicaid
Summary: Outpatient Variability
• antibiotic prescribing at sick visits varies
significantly across practice sites
• broad-spectrum antibiotic prescribing at sick
visits varies significantly across practice sites
• adherence to prescribing guidelines for AOM,
sinusitis, GAS pharyngitis, and pna varies
significantly across practice sites
Study Design
• cluster-randomized controlled trial
• bundled intervention vs. no intervention
• unit of observation will be the practitioner
but randomized at practice level
– natural distribution of physicians
– avoids intra-practice contamination
Intervention
1. guideline development
2. education
3. prescribing audit and feedback
Study Setting: CHOP Care Network
5 urban, academic
24 “private”

urban

suburban

rural
Outcomes
VIRAL
common cold
URI
acute bronchitis
tonsillitis
pharyngitis (non-strep)
BACTERIAL
acute sinusitis
Strep pharyngitis
pneumonia
no antibiotics
penicillin/amoxicillin
Case Definitions
• ICD9 codes for common infections
(+/- GAS testing, antibiotic use)
verified by chart review and provider feedback
• Excluding:
– antibiotic allergy
– visit within prior 3 months with antibiotic
– concurrent bacterial infection
• AOM, SSTI, UTI, lyme, acne, chronic sinusitis,
mycoplasma, scarlet fever, animal bite, proph, oral
infections, pertussis, STD, bone/joint
– children with complex chronic diseases
Intervention: Timeline
Feedback reports
Site presentation
12 months
baseline data
12 months of 12 months after
audit/feedback feedback ends
*
*
*
*
Broad-Spectrum per Sick Visit
Excluding: preventive visits, CCC, antibiotic allergy, prior antibiotics
Standardized by: age, sex, age-sex, race, Medicaid
Broad-Spectrum for Specific Diagnoses
Excluding: preventive visits, CCC, antibiotic allergy, prior antibiotics
Standardized by: age, sex, age-sex, race, Medicaid
History of Antimicrobial Use
History of Antimicrobial Use
•
2000 B.C.
– “Here, eat this root.”
•
1000 A.D.
– “That root is heathen. Here, say this prayer.”
•
1850 A.D.
– “That prayer is superstition. Here, drink this potion.”
• 1940 A.D.
– “That potion is snake oil. Here, take this penicillin; it’s a
miracle drug.”
• 1985 A.D.
– “Penicillin is worthless. Here, take this new antibiotic; it’s
bigger and better.”
• 2000 A.D.
– “Those antibiotics don’t work any more. Here eat this root.”
Summary/Future Directions
• ASPs improve outcomes, reduce use, and
save money. Probably reduce resistance.
• ASP requires coordinated team effort,
administrative support, and DATA
• Pediatric surgery and primary care are
potential targets for ASP; look at the data
Thank You
• Questions?