Flushing Hospital Medical Center
Antimicrobial Stewardship Program
Presented by:
Judith Fine, MSc, MPH, M(ASCP); Director of Infection Control
Rehana Jamali, PharmD
Medication Safety Officer
Flushing Hospital Medical Center
Flushing Hospital
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Local Community Hospital incorporated since 1884.
Certificate of Occupancy:
Med Surg beds
ICU beds; Medical/ Coronary/ Surgical/ NICU.
Percentage of Medicare/ Medicaid NH patients 70-80%
Scope of services rendered:
Pediatrics, Maternal Child, Level III NICU, Med/ Surg, Geriatrics,
Continuum of Care; TCU, Hospice.
High Bioburden- community onset ( NH) MDRO incidence
High Foreign born patient population.
Antimicrobial Stewardship
Committee Members
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ANTIMICROBIAL STEWARDSHIP COMMITTEE
Deborah Asnis, MD, Chairperson, Director Infectious Disease
Peter Barra, MD, Medical Director, Administration
Zeinab El Boghdadly, MD, Resident PGY3, Medicine
Roseann Ciuffo, MD, Physician, Infectious Disease
Robert Crupi, MD, Chairman, Emergency Room
Raffaela Dellino, R.Ph., Supervisor, Pharmacy
Jaime Devera, RN, Assistant Director, Nursing
Esra Fakioglu, MD, Pediatric, Infectious Disease
Catherine Ferrari, RN, Administrator, Administration
Judith Fine, MSc, MPH, M(ASCP) Director, Infection Control
Minerva Garcia, Supervisor, Microbiology
Tae Hahn, R.Ph, MS, Pharm D, Assistant Director, Pharmacy
Rehana Jamali, Pharm D, Medication Saftey Officer, Medisys Informatics
Alexander Kintzoglou, MD, Chairman, Medicine, Dept. of Medicine
Kelly McGuire, RD, CDN, Clinical Dietitian, Nutrition
Siamack Nemazie, Cheif Medical Informatics Officer, Medisys Informatics
Martha Niederland, MD, Chairwoman, Pathology
Ruben Silvestre, RN, Director, Nursing Administration
Iqbal Tak, Physician, Infectious Disease
AST Program
• Aim to promote rational antimicrobial prescribing with the goal of
reducing the incidence of Multi-Drug Resistant Organisms (MDROs)
infections
• Correlation between antibiotic prescribing patterns and antibiotic
resistance
• Optimize the selection, dose, duration, and route of therapy with the
most appropriate drug for the patient’s condition
• Recommendations: use an alternative therapy, de-escalate to an
oral alternative, or to use no therapy, when necessary
AST Program
• Strategies:
– Antibiogram published annually – local antibiotic susceptibility data,
selection of empirical antibiotic therapy only
– Monitor restricted antibiotics – initial orders, dosing, duration, deescalation based on C&S results or discontinuation, dose adjustments
based on renal function
– Guidelines
• Renal function assessment – creatinine clearance calculation
• Clostridium Difficile Infection management
– Antibiotic Order Sets
– Education
– Outcomes
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Reduction in Adverse Drug Events
Antimicrobial Resistance
Reduce Length of Stay – IV to PO conversion program
Cost containment
2012 Antibiogram
2012 Antibiogram
Utilization and Cost
Medication/NDC
Charge
Cost/unit Charges Total Cost Charges Total Cost April
Febraury
March
Total Cost
PIPERACILLIN SOD-TAZOBACTAM SO 3-0.375 G IV SOLR [18303]
PIPERACILLIN SOD-TAZOBACTAM SO 2-0.25 G IV SOLR [18304]
PIPERACILLIN SOD-TAZOBACTAM SO 4-0.5 G IV SOLR [18302]
Pipercillin/Tazobactam
$3.22
$4.72
$6.58
1320 $4,250.40
783 $3,695.76
1
$6.58
2104 $7,952.74
1,253
759
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2,013
$4,034.66
$3,582.48
$6.58
$7,623.72
1,242
528
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1,770
$3,999.24
$2,492.16
$0.00
$6,491.40
CEFEPIME HCL 1 G IJ SOLR [16369]
CEFEPIME HCL 2 G IJ SOLR [16371]
Cefepime
$3.41
$6.01
676 $2,305.16
28 $168.28
704 $2,473.44
603
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625
$2,056.23
$132.22
$2,188.45
380
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415
$1,295.80
$210.35
$1,506.15
IMIPENEM-CILASTATIN 500 MG IV SOLR [9603]
IMIPENEM-CILASTATIN 250 MG IV SOLR [9602]
Imipenem/cilastatin
$5.00
$9.53
223 $1,115.00
313 $2,982.89
536 $4,097.89
200
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442
$1,000.00
$2,306.26
$3,306.26
130
141
271
$650.00
$1,343.73
$1,993.73
$110.58
$99.51
46 $5,086.68
42 $4,179.42
88 $9,266.10
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90
99
$995.22
$8,955.90
$9,951.12
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81
$3,317.40
$5,075.01
$8,392.41
30 $8,412.90
30 $8,412.90
35 $9,815.05
35 $9,815.05
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$17,106.23
$17,106.23
LINEZOLID 2 MG/ML IV SOLN [28226]
LINEZOLID 600 MG PO TABS [28224]
Linezoild
DAPTOMYCIN 500 MG IV SOLR [36989]
Daptomycin
$280.43
MDRO resistance patterns
E.coli CRE
MDRO resistant patterns
K.pneum. CRE
C. Difficile annual comparison
Antimicrobial Stewardship
Program Gap Analysis
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Antimicrobial Use Data
Microbiology Data Administration/Informatics/Medical Staff
Stewardship Strategies
Data collection
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Best Practices
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Determine Defined daily dose calculation for certain antibiotic and report it on a
monthly basis Look for trends on a monthly basis for any significant variances in units
purchased and dollars spent
Antimicrobial Stewardship
Program Gap Analysis
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IV to PO Conversion Program
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Antibiotic Restrictions
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Renal dosing adjustments
Empiric Antimicrobial guidelines
Diagnosis driven/ clinical syndromes
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CAP( Community Acquired Pneumonia )
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HCAP (Health care associated Pneumonia)
Complicated Skin and Skin Structure Infection
ComplicCNS infection (meningitis/Encephalitis) ated Urinary Tract
Infection
Severe Diarhhea suspected C.diff
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( previous Hx, NHR, Hx of antibiotics, immunosuppressed)
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Septic Arthritis
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Antibiotic order sets to be built into the Electronic Medical record.
Order sets to document: empiric/ therapeutic/ prophylaxis as per the CMS
requirements for survey preparations.
C. Difficile guidelines
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Clostridium Difficile Infection (CDI) Guidelines
Symptoms:
Mild to moderate C. difficile disease:
Watery diarrhea three or more times a day for two or more days
Mild abdominal cramping and tenderness
Severe C. difficile disease:
C. difficile causes the colon to become inflamed (colitis) or to form patches of raw tissue that can bleed or produce
pus (pseudomembranous colitis). Signs and symptoms include:
Watery diarrhea 10 to 15 times a day
Abdominal cramping and pain, which may be severe
Fever
Blood or pus in the stool
Nausea
Dehydration
Loss of appetite
Weight loss
Risk Factors:
Recent antibiotic use
Age 65 years of age or older
Recent hospitalization, especially for an extended period
Nursing home or long term care facility
Recent chemotherapy use or suppressed immune system as a result of a medical condition.
Abdominal surgery or a gastrointestinal procedure
Inflammatory bowel disease or colorectal cancer
Previous C. difficile infection
Testing and Diagnosis
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Testing for C. difficile or its toxins should be performed on diarrheal (unformed) stool, unless ileus due to C. difficile is suspected.
Testing for stool from asymptomatic patients is not clinical useful
C. Difficile Guidelines
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2 step method that uses a confirmatory test of C difficile antigen and C. difficile toxin A and
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Polymerase Chain Reaction (PCR) testing - highly sensitive and specific, potential for false positive results
Repeat testing during the same episode is diarrhea is discouraged.
Colon examination - flexible sigmoidoscopy to detect areas of inflammation and pseudomembranes
Imaging tests - CT scan
Isolation/Infection Control
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Enzyme Immunoassay (EIA) for C. difficile GDH antigen - highly sensitive, cannot distinguish between toxigenic and
nontoxigenic strains
Enzyme Immunoassay (EIA) for C. difficile toxins A and B - sensitivity is about 75 percent; the specificity is high (up to 99
percent), relatively high false negative rate since 100 to 1000 pg of toxin must be present for the test to be positive
When to initiate isolation?
When to discontinue isolation?
Who can write orders for it?
Clinical Pathway for CDI
Order only 1 C. difficile assay
Discontinue anti-diarrheals and unnecessary antibiotics
Begin empiric treatment
Begin Contact precautions/isolation
Signs and Symptoms of CDI
antigen (-); toxin A/B (-)antigen (+); toxin A/B (-)antigen (+); toxin A/B (+)Tests:
Please note that only one test should be ordered. Multiple tests should be avoided.
PCR testCDI present:
Continue contact isolation (duration is until patient does not have diarrhea for at least 48 hours)
Continue treatment (duration below)CDI not present:
Discontinue CDI isolation
Provider must document in chart that the diarrheal symptoms are not associated with Clostridium Difficile Infection
Consider discontinuing CDI treatment and investigating other causes of diarrhea
Signs and Symptoms improve:
Complete course of therapy
No further toxin assaysBegin therapy for severe disease
Obtain abdominal/pelvic CT scan No improvement of diarrhea in 5 daysPositiveNegative
Testing Interpretation for CDI
EIA assay AntigenEIA Assay ToxinInterpretationRecommendationsNegativeNegativeNo C. difficile presentDiscontinue contact isolation and treatment. No
repeat testing.PositivePositiveC. difficile presentContinue contact isolation therapy. No repeat testing.Positive NegativeFalse negative toxin assay or nontoxigenic C. difficilePCR test to confirm toxigenicityTreatment Recommendations for CDI
Disease SeveritySupportive Clinical DataRecommended TreatmentDurationInitial episode, mild or moderateLeukocytosis with a WBC ≤ 15,000 cells/µL
and a serum creatinine level < 1.5 times the premorbid levelMetronidazole 500 mg PO every 6 hours10 to 14 daysInitial episode, severeLeukocytosis with
a WBC ≥ 15,000 cells/µL and a serum creatinine level ≥ 1.5 times the premorbid levelVancomycin 125 mg PO every 6 hours or Vancomycin 250 mg PO
every 6 hours 10 to 14 daysInitial episode, severe complicatedHypotension or shock, ileus, megacolonVancomycin 250 mg PO every 6 hours, plus
Metronidazole 500 mg IV every 6 to 8 hours Surgical interventionFirst recurrenceSame as initial episodeSecond recurrenceVancomycin in a tapered
and/or pulsed regimen
Cellulitis treatment algorithm
Barriers
• 1. Patient Population - primarily elderly patients from
Nursing Home with multiple hospital admissions
• 2. Infection Type - primarily healthcare associated
pneumonia required multiple empiric antibiotics which
are continued for prolonged period of time
• 3. Physician service - primarily voluntary physicians
admitting patients, lack of access for education and
awareness of AST initiatives
• 4. Structure of AST program - lack of dedicated ID
physician for stewardship initiatives