How to Win the War on Bugs:
EHR with Automated Antimicrobial
Prescription Surveillance System.
Presented by :
Vincent Nault PhD(c)
Presenter Disclosure
 Presenter: Vincent Nault
 Relationships with commercial interests:
 Shareholder of Lumed inc.
Disclosure of Commercial Support
Potential for conflict(s) of interest:
 Lumed inc. is the company licenced to develop and commercialize the product
that will be discussed in this program: APSS.
 Vincent Nault is also an employee of Lumed inc. and he is receiving a salary
from the same company.
Mitigating Potential Bias
 Data used in this presentation was collected before the
establishment of Lumed inc.
 Data was produced and managed by the Centre Hospitalier
Universitaire de Sherbrooke and the Université de
Sherbrooke.
Why optimizing antibiotics (Abx) ?
Major Clinical and Health Concerns
Negative impacts on patients’ health
Toxicity
Main risk factor of C. difficile
Increased length of stay
Inadequate spectrum coverage
Increased Abx resistance
Bacteria
Abx
Mutations
Resistant bacteria
It is costly
713-Bed Academic Hospital, 30 000 hospitalizations
10 000 hospitalisations
35 000 Abx prescriptions
210 000 doses
1,7 M$/ year
50% inappropriate
7
Unanimous Recommendation
Accreditation Canada
Ministère Santé et Services sociaux
Infectious Disease Society of America
It is urgent to implement Abx stewardship
Surveillance is Good…
Admission
Pharmacy
Microbiology
Laboratory
EHR
- Susceptibiliy profiles
- Length of stay
- Intervention reports
- Drug consumption
- Filter : age, ward, time, etc.
- Antimicrobials DDD
Computerized optimization is better
10
Multistep Process
Interaction
Posology
Redundancy
IV to PO
Microbiology
Cost
EHR
Pip-Tazo 3g q6h
CrCl < 20 ml/min
Pip-Tazo
+
Metronidazole
Fluconazole
+
Statin
Quinolones
WBC normal
To normal
Resistant bacteria
Unjustified use
of meropenem
Sequential Therapy
1
2
3
4+
Ceftriaxone +
moxifloxacin IV
Ceftriaxone IV
Penicillin IV
Amoxicillin PO
28$
3$
3$
0,25$
The Right Choice, the Right Time
Patient
Lab
ATM
Micro
Tx
Impacts of APSS
at the CHUS
Types of Interventions (n=2733)
Oral Abx Consumption
PO DOT/1000PD
200
180
160
140
120
100
80
60
40
20
0
APSS
PO Abx$/1000PD
1400
APSS
1200
1000
800
600
400
200
0
1
5 9 13 17 21 25 29 33 37 41 45 49
1 5 9 13 17 21 25 29 33 37 41 45 49
PO $
20000
18000
16000
14000
12000
10000
8000
6000
4000
2000
0
APSS
1 5 9 13 17 21 25 29 33 37 41 45 49
Pre
Post
Pre
Post
Pre
Post
Linear (Pre )
Linear (Post)
Linear (Pre )
Linear (Post)
Linear (Pre )
Linear (Post)
Time-series analysis; p<0.05
IV Abx Consumption
IV DOT/1000PD
300
APSS
250
IV Abx$/1000PD
10000
APSS
IV $
140000
APSS
120000
8000
100000
200
6000
80000
4000
60000
150
100
40000
2000
50
20000
0
0
1
5 9 13 17 21 25 29 33 37 41 45 49
Pre
Post
Linear (Pre )
Linear (Post)
0
1 5 9 13 17 21 25 29 33 37 41 45 49
1 5 9 13 17 21 25 29 33 37 41 45 49
Pre
Post
Pre
Post
Linear (Pre )
Linear (Post)
Linear (Pre )
Linear (Post)
22% of reduction in Abx IV consumption
Time-series analysis; p<0.05
Overall Abx Consumption
DOT/1000PD
500
450
400
350
300
250
200
150
100
50
0
Abx$/1000PD
12000
APSS
APSS
$
160000
APSS
140000
10000
120000
8000
100000
6000
80000
4000
60000
2000
40000
20000
0
1 5 9 13 17 21 25 29 33 37 41 45 49
1
5 9 13 17 21 25 29 33 37 41 45 49
Pre
Post
Linear (Post)
Pre
Post
Pre
Linear (Pre )
Linear (Post)
Linear (Pre )
0
1 5 9 13 17 21 25 29 33 37 41 45 49
Pre
Post
Linear (Pre )
Linear (Post)
13% of reduction in Abx consumption
Time-series analysis; p<0.05
Direct Savings After 30 Months
APSS
Savings
$922 000
Questions ?
Conclusion
•
APSS + EHR, a proven synergy
• Reduction of 18 % in Abx expenditures
Reduction of 22 % in Abx consumption IV
• Intervention was sustainable and persistent
1
0.8
0.6
0.4
0.2
0
1 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46 49 52
Pre
Post
Linear (Pre )
Linear (Post)
PD w/o Abx
Proportion 65+
Populations
1 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46 49 52
Pre
1
Post
Linear (Pre )
Linear (Post)
10000
0.6
0.4
0.2
0
1 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46 49 52
Pre
Post
Linear (Pre )
Linear (Post)
PD w/ Abx
0.8
Proportion
9000
8000
7000
6000
5000
4000
3000
2000
1000
0
8000
6000
-2500 PD
year
4000
2000
0
1 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46 49 52
Pre
Post
Linear (Pre )
Linear (Post)
Targeted ATM (n=2733)
Impact of stewardship on CDI
Valiquette et al. CID 2006.
Return to baseline in 2 years
-54%
-22%
-43%
-6%
Interventions
From August 2010 to August 2012
61 654
prescriptions*
2733 accepted (91%)
278
Physician refused
38718 no error
3011
22 936
17 116 not reviewed
2809
Pharmacist disagreed
5820