Antimicrobial Stewardship:
Working Together to Improve
Prescribing
NYC APIC Chapter Meeting
May 16, 2012
Belinda Ostrowsky, MD, MPH
Itinerary
Departure: APIC Meeting, Lenox Hill Hospital, NY Departure Time: 5/16/12 2:30pm
Destination: Judicious Use of Antimicrobials
Arrival Time: 5/16/12 3:30pm
I
What is antimicrobial stewardship?
Why is antimicrobial stewardship needed?
II Does antimicrobial stewardship work?
What are specific activities of antimicrobial stewardship?
What are the challenges in developing an antimicrobial stewardship
program?
III What is the status of local stewardship activities?
What are some of the use, resistance and adverse event issues in my
facility/our region (highlights)?
Antimicrobial Stewardship
-- “Antimicrobial Management Team”
Stewardship “…the careful and responsible
management of something entrusted to one's care
<stewardship of our natural resources>”
Merrian- Webster Online Dictionary 2009
Antimicrobial Stewardship
• Healthcare institutional program to ensure
appropriate antimicrobial use
– Primary goal optimize clinical outcome while minimizing
unintended consequence
• Toxicity, selected pathogens (C.difficile), emergence of
resistance
– Secondary reduce healthcare costs without adversely
impacting quality of care
IDSA/SHEA.CID 2007:44; 159-177.
Inappropriate Antimicrobial Use is Common
• Antimicrobials account for up to 30% of hospital
pharmacy budgets
• As many as 50% of antimicrobial regimens are
considered “inappropriate”
• Wrong drug, route, interval, frequency, duration
• Inappropriate use is associated with:
–
–
–
–
Increased morbidity and mortality
Increased length of stay (LOS)
Increased adverse events and antimicrobial resistance
Increased costs
Duncan. ICHE.1997;18(4):260-266.
Jarvis. ICHE. 1996;17 (8):490-495
Kollef M, et al. Chest 1999;115:462-74
Hecker MT. Arch Intern Med. 2003;162:972-978.
Unnecessary Antimicrobials
Where Do We Go Wrong?
“Unnecessary” Antimicrobial Therapy
• 129 patients/2 wk period
• 576 (30%) of 1941Antimicrobial Day
35%
30%
33%
Dur. Of Therapy Longer than
Needed
32%
25%
Noninfectious/Nonbacterial
Syndrome
20%
15%
16%
10%
5%
10%
Treatment of
Colonization/Contamination
Redundant
0%
REASON UNNECESSARY
Hecker MT. Arch Intern Med. 2003;162:972-978.
We have Bad Bugs,
No New Drugs Coming!
Total Approved Antibacterials: US
20
15
Total # New
Antimicrobial Agents
10
5
0
1983-1987
1988-1992
1993-1997
1998-2002
2003-2007
IDSA. CID. 2008; (46):155-164, (Modified)
Others are Watching (and Judging) Our
Antimicrobial Use and Resistance
• Regulatory Bodies:
– Centers for Medicaid and Medicare Services, Medicare
Quality Monitoring System (CMS)
• Shared with the public to compare different
hospitals at www.hospitalcompare.hhs.gov
– Mandatory reporting to New York State Department of
Health (NYSDOH) Healthcare Associated Infections
(HAI), including C. difficile
• Consumer advocates:
– Consumer Union- Force promoting state legislation for
“Mandatory Reporting of HAI”
What are the Factors that Influence
Antimicrobial Prescribing/Use?
Outpatient:
•Expectation for antibiotics
Inpatient:
•Teaching facilities-prescribing by trainees
•Inpatient are more acutely ill and complex
•Pressure to keep LOS short (less watch and wait)
•First priority to prevent disaster first 24 hrs (data on delay)
•Underestimate the downside to inappropriate antimicrobials
(one patient at a time and in aggregate- Medical/Family)
Avorn. Ann Int Med 2000; (33) 128-135.
Clinicians are Unlikely to Stop Therapies
on Their Own
• Study short course therapy in ICU with pulmonary
infiltrates
• Randomized trial using provider preference Vs. clinical
pulmonary scores (Prediction Tool)
Outcomes:
– Antibiotics > 3 days:
Provider Preference (90%) Vs. Prediction Tool (28%), p=0.001
– Overall mortality, ICU LOS- no difference
– Super infections, Antibiotic resistance- less in prediction tool
group
– Study stopped by IRB
Singh et al. Am J Resp Crit Care Med. 2000;162:505-511
Itinerary
Departure: APIC Meeting, Lenox Hill Hospital, NY Departure Time: 5/16/12 2:30pm
Destination: Judicious Use of Antimicrobials
Arrival Time: 5/16/12 3:30pm
I
What is antimicrobial stewardship?
Why is antimicrobial stewardship needed?
II Does antimicrobial stewardship work?
What are specific activities of antimicrobial stewardship?
What are the challenges in developing an antimicrobial stewardship
program?
III What is the status of local stewardship activities?
What are some of the use, resistance and adverse event issues in my
facility/our region (highlights)?
Do Antimicrobial Stewardship
Programs Work?
• Most of the data to support are from:
– Inpatients
– Adults
– ICU
• Comprehensive programs have consistently
demonstrated:
– Decrease in antimicrobial use (22%-36%)
– Savings of $200,000-$900,000
– Success in different facility types-large academic and
smaller hospitals
McGowen, Finland. J. Infect. Dis. 1974;134:130-165
McGowan. Rev Infect Dis, 1983;5:1033-1048
Monroe, Polk. Curr Opin Microbiology 2000;3:496-501
Courcol et al. J. Antimicrobial Chemoth 1989;23:441-51
SHEA/APIC Communication Network, Abstracted Presented at
March 2008 SHEA Annual Meeting (
www.apic.org/commnetwork)
Antimicrobial Stewardship
• There are National Guidelines
published by Infectious Diseases
Society of America (IDSA) in 2007
• Many facilities doing elements
of stewardship:
• Not under one umbrella
• Not dedicated team
• Less formal ongoing program, tracking
processes or outcomes
• Guidelines, don’t tell you how
to do this in your facility
IDSA and SHEA Guidelines for Developing an Institutional Program to Enhance
Antimicrobial Stewardship CID 2007:44; 159-177.
Guidelines, Not one size fits all
“Tailor to your own reality (needs, size and resources) ”
Components of Antimicrobial Stewardship Programs
Core Activities
Stewardship teammultidisciplinary*
Formulary restrictions
and preauthorization*
Prospective audit with
intervention and
feedback*
*Activities with the strongest data and support by
IDSA
• IDSA and SHEA Guidelines for Developing an Institutional Program
to Enhance Antimicrobial Stewardship CID 2007:44; 159-177.
Supplemental Strategies
Streamlining or de-escalation
of therapy*
Dose optimization*
Parenteral to oral
conversation*
Guideline and clinical
pathways*
Education
Antimicrobial order forms
Antimicrobial cycling
Combination therapy
Development of a Antimicrobial
Stewardship Team
• Dedicated personnel
• Multi-disciplinary
– Infectious Disease
– Pharmacy (PharmD with Infectious Diseases
/Antimicrobial Expertise)
• Support from Administration
• Strong liaisons
–
–
–
–
–
Pharmacy and Therapeutics Committee
Infection Control/Healthcare Epidemiology
Microbiology
Safety (others involved in Quality)
Health Information Technology
Core--Formulary Restrictions and
Preauthorization with Justification
PRO
• Is the most effective
method of controlling
antimicrobial use
• May be useful in
healthcare associated
outbreaks
“FRONT END”
CON
• Less clear evidence of
reducing of long term
antimicrobial resistance
– May just lead to shifts in use
and resistance
• The effectiveness depends
on who makes the
recommendations
• Mainly effects initial
regimen
– Less control over length of
use
John, Fishman. CID. 1997;24:471-485
Pear et al. Ann Intern Med. 1994;120:272-277
Bamberger et al. Arch Intern Med. 1992;152:554-557.
Freidrich et al. CID. 1999;28:1270-1271
• Prescribers have less
control (“antibiotic police”)
Core--Prospective Audit with
Intervention and Feedback
PRO
• Has been shown to improve
antimicrobials use in
facilities of differing sizes
• Data that it also decreased:
– C.difficile
– Cost
– Resistant gram negative
infections
CON
• Labor Intensive
• Have to identify opportunities
to intervene
• Can be facilitated by computer
surveillance/software
“BACK END”
• Benefits in hospital where
daily review not feasible
Solomon et al Arch Intern Med.2001;16:1897-902
Fraser et al. Arch Intern Med.1997;71:941-944
Carling et al. ICHE. 2003;24:699-706
LaRocco. CID. 2003; 37:742-743
How Can ICPs Help?
• It all the way you look at things--Q: How do we get antibiotic resistance/C. difficile/HAIs?
A: Infection control breeches, environmental cleaning
issues, transferred in, over use of antibiotics
- some combo of all of these things
•
•
•
•
•
Work together
Help with surveillance
Share data
Many places- share MD support
Share and complement policies
Elements of CDI Control Plans
Multi-pronged (including):
Tiered depending on burden of
disease
Multidisciplinary Approach
– Surveillance
– Improved microbiological
diagnosis
– Infection control
• Contact precautions, room placement,
Adapted from APIC, Guide to the elimination of
signage
C. difficile in Healthcare Settings, 2008
• Hand hygiene
Elements of CDI Control Plans (cont.)
– Environmental controls (protocols/monitoring
cleaning)
– Evidence based treatment/management CDI
cases
– Antimicrobial stewardship
– Education of patients, families and healthcare
workers
– Administrative Support
How Can You
(Nurses/Non prescriber HCWs) Help?
• Our partners in underscoring the importance of
judicious antibiotic use to clinicians (especially
housestaff) for our patients’ safety
– Nursing leadership you set the tone
– Help remind clinicians about antibiotic approvals
and consultation
– Encourage clinicians to reassess the needs for
antibiotics (stop, shorter courses, deescalatingnarrower/oral )
– Help patients and families regarding antibiotics
• Taking abx, goals of care/appropriateness of
abx (futility)
How Can You (Nurses/Other HCWs) Help?
• Help with collecting testing/cultures that will help
with diagnosis (e.g., sputum, stool for C. difficile)
– Appropriateness/ Timing
• Encourage good infection control/ environmental
cleaning to complement antibiotic stewardship
– Comply isolation/precautions, maintenance of
devices
– Assure environmental cleaning
• If you see something…. say something
Antibiotic “Stewardess”--Not that Far off
Stewardess
• Security and boarding to start
your course
• Passport
• Sees the world at 35,000 ft
Antimicrobial Stewardship
• Approval for restricted
antibiotics to start antibiotic
course
• Antibiograms is a passport to
our local microbiology
• See the hospital’s use and
resistance in aggregate (“35,000
ft” vs. just one patient at a time)
• Your safety is their priority
• Your patient’s safety and
outcome is our priority
• Recent airplane crash in NY–
“miracle” vs. flight crew
attributed to careful systems in
place and exercise by a skilled
team
• Developing systems using a
specialized team to promote
antibiotic use
Itinerary
Departure: APIC Meeting, Lenox Hill Hospital, NY Departure Time: 5/16/12 2:30pm
Destination: Judicious Use of Antimicrobials
Arrival Time: 5/16/12 3:30pm
I
What is antimicrobial stewardship?
Why is antimicrobial stewardship needed?
II Does antimicrobial stewardship work?
What are specific activities of antimicrobial stewardship?
What are the challenges in developing an antimicrobial stewardship
program?
III What is the status of local stewardship activities?
What are some of the use, resistance and adverse event issues in my
facility/our region (highlights)?
What’s the status of stewardship programs?
• Surveys Take a Pulse on Stewardship Activities:
– Network of infection control/healthcare epidemiologist and
antibiotic resistance activities in 2007: 41% of facilities had a
formal antimicrobial stewardship program
– IDSA EIN Fall 2009: 54% with stewardship programs
– New York City/tri-state area- Greater N.Y. Hospital
Association (GNYHA) 40 facilities in a C. difficile
collaborative:16 stewardship, most < 2 years old
• May be over estimates- how define stewardship program
• There are programs U.S./international are
groundbreakers
• Pharmacy community ahead
1 B .Ostrowsky et al, SHEA, Poster presentation Abstract No. 305, April 2007, Baltimore MD.
2. IDSA, EIN network, management of Inpatient Antimicrobial Use, http://www.intmed.uiowa.edu/research/ein/FinalReport_ASP.pdf
3. Internal GYNHA/UHF C. difficile collaborative data
Local Use, Resistance and Adverse Events
An Emergency Can Yield Future Opportunities
H1N1-Influenza Activities:
• ASP (with IC) lead in response:
– Algorithms (N.Y. earlier activity)
– Dissemination of quickly changing
information/recommendation
HCW
Exposures
Testing
Tamiflu
Contacts
Vaccination
Worried well
Infection
Control
Outcomes:
• Screened > 3000+ calls (release to > 1000 patients)
• 4000 webpage hits (3 weeks)/many updates
• Byproduct was relationship “goodwill” with ER
• Visibility (important to brand program)
• Helped with future ASP interventions
Pneumonia
Importance:
– Common diagnosis/large volume of antibiotics
– CMS Measures (external review)
– Many prescriber involved [including Emergency Room(ER)]
Intervention (Compliance Initial Regimen1):
–
–
–
–
–
Multidisciplinary Team (ASP, Quality and ER)
Guidelines/algorithms
Restriction issues (novel tracking- Pyxis machine)
Audits/feedback
Education
Outcomes: Improved from 65% (3rd quarter 2008) to 94%
(2nd quarter 2010, p=0.01)2
1. Initial regimen for community acquired pneumonia (CAP)
by CMS measures
2. Worked at 2 facilities- very different providers- sustained
Increased Severity of CDI
• Hypervirulent
epidemic strain
of CDI (B1/NAP1)
– Implicated in outbreaks throughout the US, Canada and
Europe
– Now seen in at least 40 US states (10/08)
– Exhibits:
• Greater toxin production
• Greater antimicrobial resistance
Compared to the current non-B1/NAP1 strains and the
uncommon historic B1/NAP1 strain
McDonald LC, et al. NEJM. 2005;353 (23):2433-2441
http://www.cdc.gov/ncidod/dhqp/id_Cdiff_data.html
C. Difficile (CDI)
• CDI is associated with:
– Increased length of stay 2.6-4.5 days
– Attributable costs for inpatient care >$2500-3500 per episode
(excluding surgery)
– In U.S. estimates > $3.2 Billion annually
– Attributed mortality rate 6.9% at 30 days and 16.7% at one
year
• Visible/tangible outcome for physicians, patients and families
• Now mandatory publically reported HAI to NYSDOH
•Dubberke et al. CID. 2008; 46(4):497-504.
• Redelings et al. EID. 2007; 139(9): 1417-1419.
•Kenneally et al. Chest ; 2007;132(2);418-424
•McDonald LC, et al. Emerg Infect Dis. 2006;12(3):409-415.
Subtyping C. difficile Isolates at MMC
Good Infection Control May Not Be Enough?
L A A B BC C D DE E E F FGGH H H L
•Assessed by Multilocus Variable Number Tandem Repeat Analysis
•Few same pattern, most unique patterns
• Geographic links – same ward, same week =same letter
• Courtesy of P. Riska, M.D.
•Pre “formal” MMC stewardship program
•“Transferred- in” or Pressure from Antimicrobial Use?
Institutional Risk Assessment
Approach to Selecting Stewardship Interventions
Case
Control
Study
Target selection
(specific antibiotic
or class)
Calculation of
Odds Ratios for
antibiotic/class
(strength of
association)
Study Patterns
of Use
Specific Questions
Regarding Antibiotics
Scenarios
Choice of Intervention
Type(s) to Address
Majority Associated
with CDI cases
Plan Implementation of Intervention
Review of aggregate
antibiotic use for each
class of antibiotics
(attributable risk)
Measure Compliance and
Impact on CDI Rates
Assess need for additional
interventions
CDC- Take an Antibiotic Time Out
From CDC Expert Commentary
Three Steps to Antibiotic Stewardship
Arjun Srinivasan, MD
http://www.medscape.com/viewarticle/731784
• Step 1. All antibiotic
orders -- a dose, duration,
and indication.
• Step 2. Make certain that
microbiology cultures are
collected.
• Step 3. When your culture
results come back in 24-48
hours, let's take an
antibiotic time-out.
Education and Outreach
• Internal
– Housestaff
– 2nd and 3rd year medical
students
– ID division
– Pharmacy
– Hospitalist
– Geriatrics
– NICU
– Nursing Leadership
– Infection Control Champions
– General staff (“Get Smart
about Antibiotic Week”)
• > 1000+
Montefiore/AECOM
staff/trainees
• External
– IDSA- poster/invited
stewardship talk
– IPRO Initiative
– AHRQ
– GNYHA
– Antimicrobial Stewardship
Certificate programNYSCHP/IDSNY
– Grand Rounds- Beth Israel,
Beekman
• > 1000+ prescribers
Other Activities (Past/ Current)
• OR and interventional cardiology area: Removal
of antimicrobial washes
• Formulary/Antibiotic subcommittee- review abx
• Dosing: Pip/tazo in ICU, Vancomycin (peds/adult)
• NICU: Meropenem use
• Work with Microbiology:Antibiograms, testing
issues (Flu, C. difficile, MRSA, MDRO GNRs)
• ER/Quality: CAP (CMS), Sepsis
Acknowledgements
• Stewardship Team- Yi Guo, PharmD,
Phil Chung PharmD, & Shakara Brown, MPH
• Liise-anne Pirofski, M.D. and Brian Currie, M.D., MPH
• MMC Hospital Administration
• MMC Microbiology- Mike Levi, PhD and Phil Gianella
• MMC Infection Control Staff
• ID Administrative Staff at AECOM and Moses
• ID Fellows
• GNYHA/UHF
Questions or comments?
Contact Info:
Belinda Ostrowsky, M.D., M.P.H.
Office 718-920-7700
bostrows@montefiore.org
Our mom says,
“Antibiotics-Don’t over use
them or you’ll
lose them!”