How to Start an Antimicrobial Stewardship Program by club56

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									How to Start an Antimicrobial Stewardship
In Conjunction with AzHHA’s Safe and Sound Patient Safety
     Patty Gray RN, CIC & Bill Wightkin, Pharm D, R.Ph
Learning Objectives

After listening to the presentation, viewing Power Point slides and
   participating in a question and answer session, the participant

   A. Be able to list the recommended components of an antibiotic
      stewardship program
   B. Be able to detect antibiotic use improvement opportunities
      from the analysis of utilization data
   C. Be able to explain the barriers for successful
      implementation of such a program
Presentation Outline

I. Why Develop an Antimicrobial Stewardship Program?
    A. Infection control nurse’s perspective
    B. Hospital pharmacist’s perspective
II. Recommended Components of a Program
III. Scottsdale Healthcare’s Program
          A. Short history
          B. Committee membership and leadership
          C. Goals of the committee
          D. Activities-to-date
          E. Results so far
          F. Opportunities for improvement
          G. Next steps
IV. Audience questions and answers
Why Develop an Antimicrobial
Stewardship Program
From an Infection Preventionist Perspective:

 Track and Reduce antimicrobial resistance

 Encourage appropriate treatment patterns ~ The right
  antibiotic, for the right duration

 Develop a collaborative practice between MDs/LIPs, Pharmacy,
  Laboratorians and Infection Preventionists’ with best patient
  outcome in mind

 Education Catalyst
Why Develop an Antimicrobial
Stewardship Program?
Hospital Pharmacist’s Perspective:

 Allows needed FOCUS on a drug class

 Need to assure appropriate medication management and safety

 Assist with educational efforts

 Assist with formulary standardization

 Control costs
               Antimicrobial Purchases

                  Yearly Expense
Daptomycin           $696,000      Expense of Top 100 Drugs:
Pip/Tazo             $585,000      $17.5 million/yr

Zyvox                $444,000      Antimicrobials = $5 million/yr
Primaxin             $415,000                29%
Caspofungin          $400,000
Levofloxacin         $338,000
Invanz               $335,000
Tygacil              $284,000
Recommended Components of an
Antimicrobial Stewardship Program

Foundation = 2   core, proactive strategies

 Prospective audit with intervention and
 Formulary restriction and preauthorization
Other Recommended Components of an
Antimicrobial Stewardship Program
 Standardized order sets and clinical pathways
  (foster evidence-based prescribing)

 Antimicrobial order forms

 De-escalation of therapy (Review C&S results; on-going review
  of therapy)

 Dose optimization (right dose for site of infection;
  renal dose adjustment)

 IV to oral dose conversion
Scottsdale Healthcare’s Program:

 Evolution from an Antibiotic Subcommittee of the P&T
 Perception of an Antibiotic Restriction and Control Approach
 Acknowledgement of Hospital and Community considerations
 Need for Administrative and Board Support
 Mission Development ~ Educational/Cooperative Focus~
 University of Kentucky Program- Dr. R. Rapp
 New Hospital with need for guidelines upon opening of facility
SHC Program~ Committee Membership
and Leadership
 Medical Staff- Active participation is critical to success
   Includes Chief Medical Officer support, ID , Hospitalists,
  Intensivists, Pulmonary, ED, Community MDs and others as
 Pharmacy- Coordinates the efforts of the team, guideline
  development, education and tracking reports
 Infection Prevention & Control- Prevention Strategies, hand
  hygiene, precautions, medical staff-nursing laison
 Microbiology- Data trends, special testing expertise
 Quality & Organizational Development- Performance
  Improvement guidance; meeting guidance
Goals of Committee

 Assist providers in appropriate use of antimicrobial therapy with
  improved patient outcomes
 Slow the development of antimicrobial resistance
 Develop evidence- based appropriate use guidelines
 Educate providers and staff regarding guidelines
 Track resistance patterns and report back to medical and
  hospital staff
 Report committee progress and outcomes to P&T, and Executive
Activities to Date

 Developed guidelines for 4 antimicrobials

 Day 7 of therapy reminder to chart

 Day 10 of therapy phone call from pharmacy ID resident

 Drug utilization evaluation (DUE)
Results so far (2 months of data)

       Drug        % of patients with an        Criteria
                    Infectious Disease      Non-Conformance
                  Physician Consultation          Rate
    Caspofungin     100% (30 patients)     23% (no de-escalation
                                           to another agent with
                                             Candida albicans)
    Daptomycin      93% (41 patients)        24% (no trial of
                                           vancomycin for skin
     Linezolid      82% (33 patients)              64%

    Tigecycline     79% (34 patients)              68%
Opportunities for Improvement

DUE reveals significant non-conformance to adopted guidelines

   Are guidelines appropriate?

   It does not appear that ID physicians are sufficiently
   engaged in the stewardship activities

Stewardship Foundation = 2 core, proactive strategies
   Is our process ROBUST (interventions after 7-10 days)??
Barriers & Opportunities for
 Cultural Perceptions- Medicine’s Heirarchy

 Integration of Team Approach and Evidenced Based Practice
  into culture

 Continued Involvement of Hospitalists & Community MDs

 Infectious Disease MDs support, agreement & use of guidelines

 Turnover of Pharmacy Leadership

 Ongoing Administrative Support
Next Steps

1. Re-evaluate physician leadership

2. Formulary evaluation: caspofungin vs. micafungin vs.

3. Transition from faculty ID pharmacist leadership to
   SHC pharmacy clinical staff

4. Explore expansion of pharmacist clinical duties to include
   antimicrobial stewardship responsibilities

5. Improvement of the 2 core proactive strategies
Next Steps

ASK WHY…...determine and address prime causative factors that have
   resulted in:

1.   Antibiotic overuse
2.   Sub-optimal antibiotic selection
3.   Too long duration of therapy
4.   Lack of de-escalation to more appropriate agents
5.   Slow switch to oral therapy

Marketing pressure?
Workload issues with poor attention to detail?
Insufficient pharmacy involvement?

  Dellit TH, Owens RC, McGowan JE, et al. Infectious Diseases Society of America
  and the Society for Healthcare Epidemiology of America guidelines for
  developing an institutional program to enhance antimicrobial stewardship.
  Clin Infect Dis. 44 (1): 159-177, 2007.

 McQuillen DP, Petrak RM, Wasserman RB, et al. The value of infectious disease
 specialists: Non-patient care activities. Clin Infect Dis. 47:1051-1063, 2008.

  Spellberg B, Guidos R, Gilbert D, et al. The epidemic of antibiotic-resistant
  infections: A call to action for the medical community from the Infectious
  Diseases Society of America. Clin Infect Dis. 46 (2): 155-164, 2008.
Antimicrobial Stewardship


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