How to Start an Antimicrobial Stewardship Program In Conjunction with AzHHA’s Safe and Sound Patient Safety Initiative 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 will: 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 feedback 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: History Evolution from an Antibiotic Subcommittee of the P&T Committee 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~ Stewardship 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 willing 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 Committees 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 infections) 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 Improvement 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. anidulafungin 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? Education-Training-Competency? Workload issues with poor attention to detail? Insufficient pharmacy involvement? http://id2.wustl.edu/~casabar/downloads/antibioticstewardship08.pdf References 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 QUESTIONS?