A Call For Stewardship

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					A Call For Stewardship
MN Chapter of the Association of Professionals in Infection Control and Epidemiology (APIC) September 28, 2009 Kimberly Boeser, ID PharmD. University of Minnesota Medical Center, Fairview

• Define “stewardship” and Antimicrobial Stewardship • Review Infectious Disease Society of America (IDSA) and Society of Healthcare Epidemiology in America (SHEA) 2007 Guidelines for Antimicrobial Stewardship • Steps for development of a stewardship program-getting started • Overview of keys for implementation success • Goals, roles and procedures of an antimicrobial stewardship program • Measurements & outcomes • Obstacles, triumphs and the future

Healthcare-associated Infections & the Impact
• CDC focuses on healthcare-associated infections
– how they happen? – develop appropriate interventions

• A report from CDC updates previous estimates of healthcare-associated infections
– – – – 32% UTI 22% SSI 15% PNA 14% bacteremias

• Healthcare-associated infections:
– account for an estimated 1.7 million infections – 99,000 associated deaths each year – Total cost annually= $5 billion

Background-A Need for Stewardship
• Increasing prevalence of resistant bacteria
– Multi-Drug Resistant Organisms (MDRO)

– Over the past decades MDRO have steadily been rising

• • •

Increased morbidity and mortality Increased Antimicrobial expenditures Decrease in market research and development
– – – – Very few antimicrobials are currently in the pipeline takes ~10 years to bring a new agent to market An investment of $800 million to $1.7 billion 56% decrease in antimicrobial approval from the FDA (1983-87 to 1998-2002)


Focus of National Quality Organizations
– Institute for Healthcare Improvement (IHI) – JCAHO National Patient Safety Goal

Increasing prevalence of resistant bacteria & Increased morbidity and mortality

Methicillin Resistant S. aureus (MRSA)-Hospital Acquired
• First isolates of MRSA reported in 1968 • CDC reported 2% staphylococcal infections were MRSA in 1974
– 1990’s-Alarmingly increased to 20-25% – 1999-reported as >50% – 2003-NNIS reported at 59.5% in ICU’s

• High fatality for certain MRSA infections
– Bacteremia – Poststernotomy mediastinitis – Surgical site infections

• Mortality may increase with S. aureus isolates w/ reduced susceptibilities
– – – – MIC creep CoNS (S. epidermidis) MIC >2 VISA or VRSA Treatment failures

Vancomycin Resistant Enterococcus

• Enterococci leading cause of many infections
– Nosocomial bacteremia – Surgical wound infections – Urinary tract infections

• Third most acquired nosocomial infection
– Reported as 10-12% – Inhabit the bowel – Hardy organisms-tolerate many environments

• Most enterococcal infections are due to
– E. faecalis -isolated from ~80% of human infections – E. faecium

• Mortality Rates of 60-70% directly related to VRE

ESBL Gram Negative bacilli
• Similar adverse outcomes reported with antibiotic resistant GNR bacteria • Increasing resistance to beta lactams, fluoroquinolones, aminoglycosides and even carbapenems
– 1997 SENTRY Antimicrobial Surveillance Program K. pneumoniae resistance rates to Ceftaz and other 3rd generation cephalosporins
• • • • Bacteremia 6.6% Pneumonia 9.7% Wound infections 5.4% UTI 3.6%

– 2003 NNIS ICU isolates of K. pneumoniae resistance reported to same drugs
• 20.6%

-the conducting, supervising, or managing of something; especially : the careful and responsible management of something entrusted to one's care

Antimicrobial Stewardship
• What??? Is often the response

• Definition: the appropriate selection, dosing, route and duration of antimicrobial therapy

Antimicrobial StewardshipGoals
• Primary Goal: optimize clinical outcomes, while minimizing unintended consequences of antimicrobial use – Toxicity – Selection of pathogenic organisms (MRSA, VRE, ESBL gram negative bacteria)
• Emergence of RESISTANCE

• Secondary Goal: reduce health care costs w/out adversely impacting quality of care

Antimicrobial StewardshipSupport
• Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America Guidelines for Developing an Institutional Program to Enhance Antimicrobial Stewardship: CID 2007 • Support – American Academy of Pediatrics – American Society of Health-System Pharmacists – Infectious Diseases Society for Obstetrics and Gynecology – Pediatric Infectious Diseases Society – Society for Hospital Medicine – Society of Infectious Diseases Pharmacists – Society for Healthcare Epidemiology of America – Infectious Diseases Society of America

How did we get started?

Background and a Call for a Stewardship Program
• Proposal developed and presented to senior leadership for approval
– UHC best practices, resistance trends, costs – Recommendations included: 1.0 FTE Pharmacist, 0.5 FTE Medical Staff
• 0.35 FTE medicine • 0.15 FTE pediatrics

– Covered the responsibilities of the service, measurements and implementation plan

Costs Analysis
• UMMC, Fairview has a $32 million operating drug budget • Anti-infectives accounted for 10% of the total budget • Compared to UHC Best Practices UMMC, Fairview ABx $/patient day were higher than average

Total Anti-infective costs University Campus
$6,000,000 $4,000,000 $2,000,000 $0 FY 03 FY 04 FY 05 FY 06 FY 07

Antimicrobial Management TeamUMMC, Fairview: Key Components
• Action Plan for Implementation
 January 2007

• Development of Guidelines for “restricted antibiotics” • Patient Monitoring Forms/Review Process • Education to medical and pharmacy staff • Rounds with Medicine ID, Surgical ID, and Pediatric ID • Establish Measurements • Obstacles-predict • Outcomes

Getting Started
• Identify the problems with our old system

• Creating a policy- “Antimicrobial Stewardship & Restricted Anti-infective Agents”
• Generate a list to flag the “restricted antibiotics”
 20 restricted agents  spectrum of activity, potential for emergence of resistance, adverse effect profiles and cost

• Establish interventions
 12 interventions

• Develop monitoring tool
• Create antibiotic guidelines for each agent

• • • Change to more appropriate antibiotic based on lab data Change to alternative unrestricted anti-infective Discontinue one or more antibiotics (PO or IV)

• • • • • • • •

Change from IV to PO antibiotics
Better empiric antibiotic therapy Antibiotic dosage change Consult recommended (eg. Infectious Disease, Pulmonary/Critical Care, Renal, Urology, etc.) Additional/Further diagnostic testing recommended Simplify antibiotic regimen (eg. Inpatients on redundant or excessively broad spectrum antibiotics Recommend change in post-op antibiotic duration Other Agree with management

Antibiotic Guidelines
• Address the following:
      Reason for restriction of agent FDA Approved Indications UMMC/UMCH, Fairview Approved Indications Dosing recommendations Monitoring Cost information

• Antibiotic Guidelines printed into a booklet that was distributed to medical students, medical residents, medical staff, pharmacy staff and students

• to Medical Staff and Residents and Pharmacy Staff • Presentation to Medical Grande Rounds • Presented and distributed the Guideline Booklets to medical residents and pharmacy • Met with unit/department medical directors • Education/presentation to pharmacy staff

Role of the AMT
• Daily rounds with medicine and surgery • Tuesday/Thursday rounds with Pediatrics • Review all patient data and antibiotics
 Do restricted agents meet our guidelines for use?

• Verbal and written recommendations
 Electronic notes  Talk to the primary teams

• Follow up in 24 hours that recommendation were accepted
 If not, address the issue with the teams  Pharmacist and Staff Physician discuss with Primary team Staff

• Monthly antibiotic utilization –Number of doses dispensed • Antibiotic cost per patient day • Interventions and acceptance rates

• Average number of antibiotics –Per patient day –Per patient visit • Correlation with resistance patterns

Utilization of Anti-infectivesHurdles
• Increase of 3,200 patient days from 2006 to 2007 • Expansion of our Adult Bone Marrow Transplant unit • Antibiotics prescribing opened for upfront use with no restriction

• New class of medical residents not all aware of the guidelines for use of restricted agents

Implementation of Stewardship Program: January 2, 2007








$Jul-06 Aug-06 Sep-06 Oct-06 Nov-06 Dec-06 Jan-07 Feb-07 Mar-07 Apr-07 May- Jun-07 Jul-07 Aug-07 Sep-07 Oct-07 Nov-07 Dec-07 07 Actual Base Line Trend Line

$70.00 Increased Utiliazation of a nonformulary agent








$Jul-07 Aug-07 Sep-07 Oct-07 Nov-07 Actual Dec-07 Base Line Jan-08 Trend Line Feb-08 Mar-08 Apr-08 May-08

Antimicrobial Cost per Patient Day (2005-2008)

Antimicrobial Agents Activity Antimicrobial Agents Total Cost Total Patient Days Antimicrobial Agent Cost per Patient Day Change


University Campus 2006 2007

2008 4,396,983 99,090 $44.37 $4.58

$5,712,589 $4,954,776 $4,841,578 96,791 $59.02 95,709 $51.77 $7.25 98,910 $48.95 $2.82

Intervention Data (2007)
Totals 1143 1991 1153 (57.9%) 370 (18.6%) 468 (23.5%)

# Patients # Interventions Accepts Agree with Management Declines

• Gaining trust of the primary teams • Recommendations taken and changes made within 24-48 hours • Overcoming the idea this is only a “cost savings” project • Conversion from paper notes to electronic record: =/• Information systems: Tracking resistance rates

Keys To Success
• ID staff support, medical unit director support, department director support

• Communication to primary teams
• Recommendations that are evidence based and follow national guidelines

• Collaboration & Multidisciplinary Approach
• DATA, DATA, DATA !!! • Show me the $$$ • Keeping in mind, “What is best for our patients as a whole” • Early wins

Future Plans
• Clinical Measurement Plan
– Expansion of other antibiotics

• Development of Clinical Pathways for disease states • Annual update of Antimicrobial Guideline Booklet • Incorporate our guidelines into electronic ordering • Expansion of Stewardship Program to other Fairview System Hospitals • Publishing our data: including cost and impact of antimicrobial utilization on resistance trends

Last Thought…
• “When you want to cook a frog, they say, don’t throw it into boiling water-it will only jump out. Instead place the frog in tepid water and, ever so slowly increase the heat.” Extending the Cure Campaign • Much like the frog, our awareness of resistance (danger) is there. The steady increase of resistance is known…but are we waiting for a crisis to respond?

• Department of Pharmacy
– Pam Phelps

• Infection Prevention Department
– Chris Hendrickson – Anita Guelcher – Sue Garayalde

• Dept. of Surgery, Pediatrics and Medicine physicians who have participated with AMT
– Greg Beilman, Matthew Byrnes, Jeff Chipman – Mark Schleiss, Mark Robein, Pat Ferierri – Phil Peterson, Susan Kline, Winston Cavert, Paul Bohjanen, Dave Boulware, Bryan Rock, Tim Schacker, Mark Cannon, David Strike

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