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: 30 pm Destination: Judicious Use of Antimicrobials Arrival Time: 5/16/12 3: 30 pm 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 “Unnecessary” Antimicrobial Therapy • 129 patients/2 wk period • 576 (30%) of 1941 Antimicrobial Day Hecker MT. Arch Intern Med. 2003; 162: 972 -978.
We have Bad Bugs, No New Drugs Coming!
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: 30 pm Destination: Judicious Use of Antimicrobials Arrival Time: 5/16/12 3: 30 pm 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 Mc. Gowen, Finland. J. Infect. Dis. 1974; 134: 130 -165 Mc. Gowan. 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 (Pharm. D 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 La. Rocco. 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: 30 pm Destination: Judicious Use of Antimicrobials Arrival Time: 5/16/12 3: 30 pm 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/Final. Report_ASP. pdf 3. Internal GYNHA/UHF C. difficile collaborative data
Local Use, Resistance and Adverse Events
An Emergency Can Yield Future Opportunities H 1 N 1 -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 Regimen 1): – – – Multidisciplinary Team (ASP, Quality and ER) Guidelines/algorithms Restriction issues (novel tracking- Pyxis machine) Audits/feedback Education Outcomes: Improved from 65% (3 rd quarter 2008) to 94% (2 nd 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 (B 1/NAP 1) – 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-B 1/NAP 1 strains and the uncommon historic B 1/NAP 1 strain Mc. Donald 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 • Mc. Donald 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) Review of aggregate antibiotic use for each class of antibiotics (attributable risk) 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 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 – 2 nd and 3 rd 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 program. NYSCHP/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, Pharm. D, Phil Chung Pharm. D, & Shakara Brown, MPH • Liise-anne Pirofski, M. D. and Brian Currie, M. D. , MPH • MMC Hospital Administration • MMC Microbiology- Mike Levi, Ph. D 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!”
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