(Pseudo) Antimicrobial
Stewardship Program in a
Critical Access Hospital
Presented by Karen Burk RPh
Clinical Pharmacy Coordinator
Powell Valley Healthcare
Who we are…
• 25 bed Critical Access Hospital in rural
Wyoming-also cover another 25 bed CAH 30
miles away
• 4 Full time pharmacists including myself and
our pharmacy director
• 3 Full time technicians
• 1 Full time secretary
Who we are cont’d…
•
•
•
•
•
•
6 Family Practice physicians
5 OB physicians – 3 are also Family Practice
1 Internal Medicine/Pediatrician
1 Orthopedic surgeon with 1 PA and 1 NP
1 General surgeon
1 ER physician-down from 4-locums filling in
AND…
• ZERO Infectious Disease Specialists
What are the goals of an
Antimicrobial
Stewardship Program?
Goals of an ASP
• Improve patient care and health outcomes
o Work with health care practitioners to
help each patient receive the most
appropriate antimicrobial with the correct
dose and duration.
o Reduce patient’s length of stay
o Reduce money spent for patient and
facility
Goals of an ASP cont’d
• Prevent antimicrobial overuse, misuse and
abuse
o Avoid unnecessary use of antibiotics.
o Minimize the development of resistance
Approaches to Antimicrobial
Stewardship
• 2 major approaches:
o Front-end or preprescription approach uses restrictive
prescriptive authority
• Restrict certain antimicrobials and require prior
authorization
o Back-end or postprescription approach uses
prospective review and feedback
• Review current antibiotic orders and recommend
to continue, adjust, change or discontinue the
therapy based on available microbiology results
How we started
• Process of evolution-one step at a time
• Utilized information from previous facilities
• Routinely review list serves such as American Society
of Health System Pharmacists. Encourage you to
join Mountain-Pacific Quality Health list serve
Developed Pharmacist
Driven Protocols
• Aminoglycoside and Vancomycin protocols were
developed and approved through the Pharmacy
and Therapeutics Committee
o Pharmacist performs all dosing and monitoring of
the patient
o Able to order labs as appropriate
Developed Pharmacist
Driven Protocols
• Renal dosing of certain medications by the
pharmacist as approved by the P&T committee
o 35 medications can be modified based on
creatinine clearance
o Able to order labs as appropriate
Hospital Protocols
• Community acquired Pneumonia
o Standards originally were antibiotics within 4
hours of entering the ED but then relaxed to 6
hours
o We kept ours at 4 hours
Physician Standing
Orders
• Changed our post op antibiotic order sets to
discontinue last prophylactic dose by 23 hours of
end of surgery
Monitoring form
• Developed an excel spreadsheet to assist in patient
monitoring by the pharmacists
Name
MR#
Visit #
Age
Sex
Ht (in)
IBW
(kg)
-88.00
ABW (kg)
Adj Wt
BSA
-52.80
0.00
Date
Scr
CrCl
Base
INR
#DIV/0!
Allergies:
Diagnosis:
Monitoring:
Anticoag protocol
CHF?
Post OP Abx? CAP? Lovenox/Arixtra?
Renal Dosing
Intervention
Date:
Scr
~CrCl
MDRD
mg/dl
ml/min
ml/min/1
x BSA =
.73
Med rec
DVT Proph?
INR
Warf. Dose
PLTS
INR
Warf. Dose
PLTS
Notes
Ongoing issues/comments
Renal Dosing Drugs
Dose
Date:
Comments
Scr
~CrCl
MDRD
mg/dl
ml/min
ml/min/1
x BSA =
.73
Notes
Ongoing issues/comments
Renal Dosing Drugs
Dose
Comments
PLT
Name
MR#
Visit #
Allergies:
NKDA
Diagnosis:
pneumonia
Monitoring:
CHF?
Anticoag protocol
Renal Dosing
Date: 1/27/13
Notes
Ongoing issues/comments
Age
Sex
Ht (in)
IBW
(kg)
ABW (kg)
97
Male
73
79.90
54
Post OP Abx?
CAP? Lovenox/Arixtra?
Adj Wt
BSA
Date
Scr
CrCl
1.67
27-Jan
1.5
21.50
Base
INR
113.00
Med rec
DVT Proph?
Intervention
Scr
~CrCl
mg/dl
ml/min
MDRD
ml/min/1
.73
INR
Warf. Dose
PLTS
x BSA =
Pneumonia, lfts elevated, cr elevated. WBC 15.4 with 83.6% neuts. Was in ER 24 hours ago with sinusitis and sent home on abx and
nasal steroids. Has been in a failure to thrive pattern for last several years. Was 220 pounds and now 118. Received 500mg iv
levaquin in ER. Will change to 250mg IV daily for renal dosing. Vitals stable. Afeb since admit.No MD notes yet.
Check for sputum culture
Renal Dosing Drugs
Dose
Comments
Levaquin
250mg IV daily
1st dose 500mg in ER 1/27/13
PLT
Working with Infection
Prevention RN
• Excel spreadsheet with basic information on new
admits with an infectious process going on
• Work together on antibiogram with Lab and IP RN
Date
07/06/2011
Comm
X
06/30/2011
Hosp
LTCC
Transf
?
x
Source
Organism
Comments
UTI
pending
pt admit 8/4/11, UA done 8/5/11, likely patient had this
UTI prior to admit. Note: patient has a hx of MRSA, wound
cultures from our ER end of last month were positive for
MRSA
UTI
E. Coli
Treated w/ Keflex. Flagyl added for potential C diff.
07/14/2011
x
UTI
?
Never did ua before starting. She had confusion so they
assumed uti.
07/16/2011
x
Osteomyelitis
Pseudomonas
Sensitive to zosyn but this strain is positive for inducible
beta lactamase
Urine
1+ budding yeast & trace
bacteria
not treated at this point, culture not set up. Transferred in
from skilled-nursing facility
x
urine
unknown/mixed flora
pt had a uti before being admitted to the hospital. Was
treated with cipro 500mg bid at home.
x
UTI
MRSE
Received 2 doses IM rocephin in ER and started on
tetracycline for at home
07/29/2011
x
diabetic foot
few gram + cocci
On zosyn. Was started on zyvox per ID in regional hospital
then changed to zosyn
07/27/2011
x
facial cellulits and
shingles
mssa
on IV acyclovir and zyvox per ID in regional hospital
07/20/2011
07/23/2011
7/26-27/11
x
Learn to think outside the box
Barriers…
• NO INFECTIOUS DISEASE PHYSICIAN!
• Reasons beyond your control- physician wants to
keep on IV abx so patient can stay in hospital or
acute care
• Doctor hangs up on you-chase him down
• Doctor is rude to you in front of other health care
professionals-try to deal with it-it’s about the patient
Barriers cont’d
o Drug reps! Luckily banned from our institution
o Lose staffing - hard to maintain standards you
have set
Barriers cont’d
• One doc thinks should be on antibiotics until the
wound is completely healed
• One doc has a treatment failure and refuses to ever
use that antibiotic again
• One doc hears about a specific med and only
wants to use that one for everyone and everything
Barriers cont’d
• Pharmacy stats for FTE’s are still based on doses
dispensed and not on clinical knowledge
Interventions
• If you didn’t document it - you didn’t do it!
CLINICAL INTERVENTIONS
1st qtr 2011
2nd qtr 2011
3rd qtr 2011
4th qtr 2011
A
321
257
231
420
B
103
70
51
130
C
197
247
127
274
D
52
51
36
19
E
7
22
7
6
F
2
n/a
n/a
n/a
Intern
20
25
46
n/a
Pharmacist
Total (assume $76/intervention)
Accepted/Denied/Unknown(%)
702
$53,352
672
$51,072
498
$37,848
849
$64,524
93/6/1
96/2/2
94/3/3
805/14/30
Anticoagulation related
101
104
63
136
Aminoglycoside/Vancomycin
13
15
11
18
Renal Dosing related
38
28
21
25
Barriers cont’d
• For clinically relevant antibiogram need at least 30
isolates
• Guess how many times we have 30 isolates in our
critical access hospital?
TE = Tetracycline
T/S = Trimeth/Sulfa
P/T = Piperacillin/Tazobactam
LVX = Levofloxacin
IMP =
GM = Gentamicin
FD = Nitrofurantoin
CRM = Cefuroxime
CPE = Cefepime
CP = Ciprofloxacin
CFZ = Cefazolin
CAX = Ceftriaxone
AUG = Amoxicillin/K Clavulanate
Organism
AM = Ampicillin
Isolates
A/S = Ampicillin/Sulbactam
Powell Valley Healthcare Antibiogram 2013
Urine Levels
Gram Negative
**NOTE: 30 isolates are required for a definitive sample size. Please take this into account when reviewing the data**
E. aerogenes
4
75%
0%
0%
100%
0%
100%
100%
75%
50%
100%
100%
100%
100%
100%
100%
E. cloacae
6
50%
33%
17%
100%
17%
100%
100%
83%
50%
100%
100%
100%
100%
100%
100%
153
66%
63%
86%
99%
93%
92%
100%
98%
99%
93%
100%
92%
99%
82%
80%
K. oxytoca
4
75%
0%
100%
100%
75%
100%
100%
100%
100%
100%
100%
100%
100%
75%
100%
K. pneumoniae
18
100%
0%
100%
100%
100%
100%
100%
100%
61%
94%
100%
100%
100%
94%
89%
P. Aeruginosa
5
40%
100%
80%
100%
40%
100%
P. Mirabilis
3
100%
100%
100%
100%
100%
100%
67%
0%
A. Iwoffii
2
C. amalonaticus
1
C. freundii cplx
1
C. Koseri
1
E. asburiae
1
E. fergusonii
1
Escherichia sp
1
M. morganii
1
S. maltophilia
2
S. marcenscens
1
E. coli
60%
33%
67%
67%
100%
67%
100%
0%
TE = Tetracycline
T/S = Trimeth/Sulfa
P/T = Piperacillin/Tazobactam
LVX = Levofloxacin
IMP =
GM = Gentamicin
FD = Nitrofurantoin
CRM = Cefuroxime
CPE = Cefepime
CP = Ciprofloxacin
CFZ = Cefazolin
CAX = Ceftriaxone
AUG = Amoxicillin/K Clavulanate
AM = Ampicillin
Organism
A/S = Ampicillin/Sulbactam
Isolates
Powell Valley Care Center Antibiogram 2013
Urine Levels
Gram Negative
**NOTE: 30 isolates are required for a definitive sample size. Please take this into account when reviewing the data**
E. Coli
5
20% 20% 80% 100% 100% 40% 100% 80% 100% 100% 100% 40%
K. pneumoniae
5
100% 0% 100% 100% 100% 100% 100% 100% 40% 100% 100% 100% 100% 80%
80%
P. Mirabilis
3
100% 0% 100% 100% 100% 0% 100% 100% 0% 33% 100%
0%
K. oxytoca
1
S. marcescens
1
0%
100% 100% 100%
100%
0%
Our partners
•
•
•
•
•
Physicians
Nurses
Lab
Infection Prevention
Patients
Physicians
• Earn respect-can take a long time to earn
and a short time to lose!
• How do your physicians like to be
contacted?
o Notes, phone, cell phone, face to face
Nurses
• Biggest allies
• Also takes a long time to earn respect and a
short time to lose it!
o RN should shadow pharmacist and
pharmacist should shadow RN
o Be persistent-will take time to turn things
around
Lab
• Utilize the experts!
• Educate regarding the antibiotics, organ
penetration etc
• D zone inhibition
• ESBL’s
• FQ not for MRSA!
Patients
• You have to be able to interact with the patient
o Compliance
o Cost
o Side effects
What we’ve tried that
didn’t work
• IV to PO conversion by pharmacist
o 1 physician hold out stopped the process
o 100% acceptance rate when we do suggest it
o I’ve heard physicians say sometimes only way to
keep patient in the hospital is to be on iv
antibiotics
Moving Towards…
• Formalizing an Antimicrobial Stewardship committee
• Physician champion
• Review requirements for non critical access hospitals to
see where we could improve
• Print a daily report from lab with culture results
• Bring in a specialist to teach providers how to obtain a
proper culture sample
• See if we can link up with an Infectious Disease physician
for consults
• Help our IP RN more with identifying patients in LTCC
How to get started
•
•
•
•
•
•
•
Identify and create your team
Identify your goals
Identify what you are already doing
Inform your facility of your plan
Create an antibiogram
Get a mentor-network
Russ Forney; list serves
Questions?
Karen Burk RPh
Clinical Pharmacy Coordinator
Powell Valley Healthcare
Phone 307-754-1179
kburk@pvhc.org
References
• Gauthier, T. & Unger, N [2013] Antimicrobial stewardship
program: A review for the formulary decision-maker.
Formulary Journal 48:7-17.
• Doron, S. & Davidson, L. 2011 Nov Antimicrobial
Stewardship. Retrieved from
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3203003/
• APIC Text of Infection Control and Epidemiology 3rd Ed
2009 Section V 62:9
• Ritter, Al, 2010 The 100/0 Principle. The Secret of Great
Relationships