Pharmacy Benefits Management Services
Antimicrobial Stewardship:
Role of IT Solutions
Melinda Neuhauser, PharmD, MPH
Richard Pham, PharmD
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Objectives
1) Describe the importance of antimicrobial
stewardship in this era of multi-drug
resistant pathogens.
2) Identify key data elements for building
tools and reports for antimicrobial
stewardship programs.
3) Demonstrate a query approach for
creating an antimicrobial usage metric
report.
What is ABX 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
 A multi-faceted approach to influence
antimicrobial prescribing, institution-wide to
improve outcomes, prevent resistance and
minimize excessive costs
IDSA Guidelines. Clin Infect Dis 2007;44:159
Resistance
Active
Agents
Why do I care?
# Antibiotics Approved
The antibiotic pipeline is nearly dry
18
16
14
12
10
8
6
4
2
0
Adapted from Clin Infect Dis. 2011;52:S397-S428
Why do I care?
http://www.idsociety.org/10x20.htm
Bad Bugs, No Drugs:
No ESKAPE!
Enterococcus faecium
Staphylococcus aureus
Klebsiella pneumoniae
Acinetobacter baumanii
Pseudomonas aeruginosa
Enterobacter species
L. Rice, JID 2008;197:1079–1081
How did we get here?
• 50% of use in hospitals is inappropriate
• Antibiotic misuse adversely impacts patients
– Antibiotic exposure is the single most important risk
factor for the development of Clostridium difficile
associated disease (CDAD).
– Getting an antibiotic increases a patient’s chance of
becoming colonized or infected with a resistant
organism.
http://www.cdc.gov/getsmart/healthcare/
Improving antibiotic use is a
public health imperative
•
•
•
Using antibiotics properly is analogous to
developing and maintaining good roads
Bringing new antibiotics into our current
environment is akin to buying a new car because
you hit a pot hole, but doing nothing to fix the road.
Fixing the “antibiotic use road” is part of the mission
of public health.
SNAPSHOT OF
VA ABX Stewardship Programs
• Many of the facilities have active stewardship
programs
• Most do not have an electronic tool to aid them
in stewardship activities
• Field requests….
– Reports for positive microbiology results
– Drug-bug mismatch
– Antimicrobial usage measurements
VA National Antimicrobial
Stewardship Taskforce
Purpose:
• Optimize the care of Veterans by developing,
deploying and monitoring a national-level
strategic plan for improvements in antimicrobial
therapy management
• Co-Chairs:
– Infectious Diseases Program Office and PBM
• Members:
– Broad multi-disciplinary representation
Committee Objectives
• Most important for this audience….
– Develop a coordinated plan to leverage
clinical information tools that support patient
care and performance measurement
IT
Specialist
Microbiologist
ABX Stewardship
Team:
Core Members
ID MD and
Pharmacist
Epidemiologist
Hospital
Admin
IDSA Guidelines. Clin Infect Dis 2007;44:159
Draft Subcommittees
• Survey
• Antimicrobial Tools and Resources
– Creation of SharePoint for Best Practices
• Metrics
• Implementation
Stewardship Activities
• Formulary restriction and preauthorization
• Prospective audit with intervention and
feedback
• Supplemental activities
–
–
–
–
–
Guidelines and clinical pathways
Streamlining or de-escalation of therapy
Dose optimization
Conversion from parenteral to oral therapy
Education
IDSA Guidelines. Clin Infect Dis 2007;44:159
Tools for Interventions
Identification of Inpatients on
Antimicrobials
Microbiology
Duration of
Therapy
Positive cultures
w/sterile body
fluids (blood, etc)
Extended
Therapy
Bug-drug
mismatches
Switch IV to oral
Positive micro
results
Dosing/Levels
Appropriate
dosing/serum
levels
Tools for Interventions
Identification of Inpatients on Antimicrobials
and Indication as part of provider order
Empiric vs
Definitive
Drop-down of
infection types
Tools for Managing Program
Measurements
Antimicrobial Use
Benchmarking
Ratio of IV to oral
therapy
Antimicrobial
Resistance
Other
Benchmarking
Duration of
antibiotic-specific
therapy linked
with/indication
Switch IV to oral
Compliance of
empiric therapy
w/guidelines
Outcomes of
C. difficle &
interventions
Proposed Antibiotic Use Metrics
• The first metrics proposed by Antibiotic
Stewardship are in the lines of information
gathering
– Antibiotic Use (AU)
– Antibiotic Resistance (AR)
Problem – We Have Little Idea
of What Data Are Available
• We do not know what our usage is!
• We have no minimum dataset
• Our data is a mess
• I’m going to show you WHAT kind a mess
this is…
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Questions That We Always Need To
Know To Make A Metric
• What are we measuring?
• Why are we measuring it? What outcome
are we trying to prevent?
• What group are we interested in measuring?
• What characteristic in the group are we
measuring?
• How is this evaluated?
Healthcare
Research
Patient
Personnel
Safety
Safety
Biovigilance
and
Development
CDC Benchmarking Tools
Antimicrobial Use &
Resistance (AUR) Option
Antimicrobial Use
Option
Antimicrobial Resistance
Option
Antimicrobial Use Option
Objective
Measure antimicrobial usage to provide riskadjusted inter- and intra-facility comparisons
Antimicrobial
Metric
Antimicrobial days / Days present
by month, patient location
Data Source
eMAR / BCMA
Implementation Partner with commercial infection surveillance
systems and electronic health record vendors
to electronically capture numerator and
denominator for importation into NHSN
Antimicrobial Usage Measurement
Antimicrobial Days
Days Present
= Metric
Example Data Elements in Report
Time Period August 2011
Location
Adult Medical Intensive Care Unit
Denominator X Days Present
Numerators
X Amikacin Days
X Amoxicillin Days
X Amoxicillin/clavulanate
X Amphotericin B
etc
Example: Risk-adjusted (MICU)
Benchmarking Output
Antimicrobial
Classes
Aminoglycosides
Facility-MICU
AU Rate:
220
Pooled
Mean
180
Percentile
Anti-MRSA Agents
480
300
93%
Carbapenems
450
320
85%
Fluoroquinolones
380
290
89%
60%
AU Metric: Antimicrobial days/1000 days present
Data for Example Only
Preliminary Numbers for Region I (VISN 1922) – FY 2011 (Rounded to Nearest 1000)
VISN
Numerator
Denominator
19
5,000
62,000
20
11,000
126,000
21
18,000
103,000
22
21,000
162,000
Defining A Population
• We need the number of hospital days a facility has
for exposure
• We get this from the Patient Treatment File (45)
• Why do we need exposure days?
– Sample representation
– Different types of unit exposure
• What is an exposure unit?
– This is hard to tell
Talking About PTF
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Talking About Inpatient
Pharmacy
• Dispense Files
– Unit Dose (UD)
– Intravenous (IV)
• Administration File
– BCMA
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Lesson Learned – Do Not Use
Dispense Files!
• Incomplete
– Automation
– PRN dosing (UD)
– IMO
• Not necessarily administered
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Ward Location
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BCMA
BCMA
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BCMA - IV
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BCMA – Dispensed Drug
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Defining A Group
• What constitutes an antibiotic day?
– Any exposure to antibiotics during that time
period
• This is hard to calculate
– Needs to be taken from BCMA
– Not IV
– Not UD
– Not Billed
Antimicrobial Days

Definition: Sum of the calendar days on which
each antimicrobial was administered
Medical Ward
Monday
December 28
Meropenem 1gm
IV every 8 hours
Given: 2300
Amikacin 1gm IV
every 24 hours
Given: 2300
Tuesday
December 29
Given: 0700
Given: 1500
Given: 2300
Wednesday
December 30
Given: 0700
Given: 2300
Schwartz D et al. SHEA Abstract #2466, Atlanta 2010.
Preliminary Numbers for Regions I and II (VISN
19-22) – FY 2011 (Rounded to Nearest 1000)
VISN
Numerator
Denominator
19
5,000
62,000
20
11,000
126,000
21
18,000
103,000
22
21,000
162,000
Problems That We Need Help
• Untangling BCMA
– Unable to Scan
– Variance
• Untangling Location
– Census of locations
• Working with local formularies
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Problems With The
Calculation
• Hospital Location
– No clear identifier what is an inpatient bed by
NHSN criteria
• Bed hopping
– Patient Movement is nearly impossible to figure
out a straight answer to where people are
• Meaningfulness
– Even if I know these numbers for antimicrobial
use, what do I do about them?
Days Present

Definition: Aggregate number of patients
housed to a patient care location anytime
throughout a day during a calendar month

Modification of “Patient Days” denominator
utilized in other NHSN Modules
Micro – The Next Domain
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Application of Benchmarking Data
• Does not assess appropriateness of use
• Tool for stewardship program
– Quality improvement efforts
– Aggregate reports of patient care locations and facility
usage
Role of IT Solutions
• Short-term goals include locally created
– Fileman Reports
– Electronic Templates for CPRS
• Potential long-term solutions may include
– National Reports available via CDW
– Infection Control Surveillance Vendors
– Validation critical before national roll-out!
Conclusions
• IT solutions are essential for antimicrobial
stewardship programs to promote the
appropriate and safe use of antimicrobials
• Please contact me directly for
– Volunteering in subcommittee
– Sharing data tools or ideas!
melinda.neuhauser@va.gov
Questions?
The views expressed in this presentation reflect those of the author, and not
necessarily those of the Department
of Veterans Affairs or Centers for Disease
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Control and Prevention.