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antimicrobial stewardship and standard 3.14…….
Matthew RawlinsID pharmacist
Royal Perth HospitalSeptember 2013
plan
• definition
• why is there a need for stewardship?
• implementation of an ASP (antimicrobial stewardship program)
• what constitutes an ASP?
• resources needed
• where to find help
definition
• optimising the selection, dosage and duration of an antimicrobial treatment in order to achieve the best clinical outcome whilst minimising toxicity, antimicrobial resistance selection and cost
Paskovaty et al. Int J Antimicrob Agents 2005 MacDougall and Polk. Clin Microbiol Rev 2005
Paterson D. Clin Infect Dis 2006 (Suppl)
Dellit et al. Clin infect Dis 2007
TG: antibiotic v14 (2010)
ACSQHC 2011
increasing resistancetrend data, Gram-negatives % multi-resistant, community
2008-2010 AGAR 2011
P=0.03 P=0.02
international benchmarking
NAUSP Annual Report 2011-12
Australia - ACSQHC publication• Duguid and Cruickshank (Eds). Antimicrobial Stewardship
in Australian Hospitals. Australian Commission on Safety and Quality in Healthcare January 2011
• Dellit et al. IDSA guidelines CID 2007
– implementation
– strategies
– resources
recommendations for implementation of an ASP (ACSQHC 2011)
• includes an antimicrobial prescribing and management policy, plan and implementation strategy
• antimicrobial formulary, guidelines for treatment and prophylaxis according to TG: antibiotic
• multidisciplinary AST (AS team)» ID physician, clinical microbiologist or lead clinician» pharmacist
• ASP resides in quality improvement and patient safety structure
• ASTs links to DTC, IPCC, clinical governance or safety and quality units
• support and training for AST member roles• process and outcome indicators are measured
antimicrobial stewardship committee (ASC)
• multidisciplinary membership
• role• directing appropriate antimicrobial use at institution
level
• TOR• chair/membership/reporting• aims and objectives
executive support (ACSQHC 2011)
• provision of resources – especially personnel time
• accreditation!• ACSQHC National Safety and Quality Health Service (NSQHS)
Standards. Standard 3: Preventing and controlling healthcare associated infections – Antimicrobial Stewardship “3.14”
• EQuIP 5 (evaluation and quality improvement program) standards and criteria from the Australian Council on Healthcare Standards (ACHS)
rationalising antimicrobial usefront end versus back end approaches
strategies (ACSQHC 2011)
• front end– formulary and approval systems
• back end – review and prescriber feedback– point of care interventions
• outcome measures and education– measuring performance (won’t go into costs)– addressing prescriber education and
competency (won’t go into)
formulary and antimicrobial approval systems (ACSQHC 2011)
– restricted list and criteria for use (TG: antibiotic)
• use by ID/Micro only or clinical specialties with suitable experience
– antimicrobial approval system• telephone/verbal• computerised (eDSS)
– rapid and targeted review facilitated
• combination
– expert advice is available• 24 hours (on call service A/H)
back end review of therapy• stewardship rounds
– identification/targeting of patients
– notes review: clinician plus pharmacist– IV to PO switch
– empirical to directed therapy
– cessation of therapy
– duration of therapy
– management advice
• recording interventions• assessment of clinician acceptance• cost savings
RAD
RAD
measuring the performance of ASP’s(ACSQHC 2011)
• IT resources– eDSS, databases, Smart phone applications,
e-prescribing, e-medical records
» for monitoring antimicrobial use
» impact of stewardship rounds
» auditing process indicators (KPIs)
» timely surgical prophylaxis, restricted antimicrobial prescribing, CAP treatment, aminoglycoside use (NSWTAG) time to first antibiotic
– measuring outcomes of ASP
• audit support– DUAG, rotations, students…..
• interpretation – of usage data with infection control and resistance data
National Antimicrobial Use Surveillance Program (NAUSP)
NAUSP Annual Report 2010-11
antimicrobial use(ACSQHC 2011)
• continuous or point-prevalence surveys– benchmarking
• international, national (NAUSP), locally
– trends• within hospital
– can they be linked to particular events?
– clinical audit of particular units/guidelines
• time series analysis (David Andresen ASA 2013)
• compare rate of increase before and after the stewardship intervention(s)
• ratio of narrow-spectrum to broad-spectrum penicillins (eg. benzylpenicillin + amoxycillin versus 3rd generation cephalosporins)
• cost savings : ASC Rounds $110-130K pa (ASA Abstracts 2006)
antimicrobial resistanceIbrahim and Polk Expert Rev Anti-infect Ther. 2012 Davis et al. ASA Abstracts 2012
Patel et al. Exp Rev Anti-infect Ther. 2008
• can reduced antimicrobial use be linked to clinical outcomes?
– mortality– readmission rates– LOS
• reality is more complex– association between use and resistance can be
shown but causality is more difficult to prove
• decreased resistance and amount of CDI have been proposed
role of ID service(ACSQHC 2011)
– lead ASP– role in formulary, expert advice, prescriber
education, guideline development, implementation and feedback
– seek external support to pharmacy or clinician lead if no ID presence on site
role of pharmacy service(ACSQHC 2011)
• admin/management support critical
• ID pharmacist• co-leader of ASP and activities
» education, promotion guideline development, implementation and audit, rounds, formulary, research
• liaison between ID/micro and pharmacy• expert advice
• (clinical) pharmacist participation• point-of-care review and interventions• knowledge and enforcement of restrictions• referral of cases• advice and education at clinical level
smaller hospitalsSeptimus and Owens CID 2011 (Suppl)
rural, smaller, non-teaching hospitals
• requirements in regional and rural setting in Australia (James et al. ECCMID Abstracts April 2013)– disparity in available resources for stewardship (esp. access to ID/micro advice and support), build
workforce capacity (pharmacists and ICPs) now leading programmes, need training and assistance to establish prescribing policies and procedures, formulary control, local guideline development and auditing
– access to education and implementation tools– model and toolkit being developed
– role of telemedicine (Siddiqi et al. ID Week Abstracts Oct 2012)– daily r/v by pharmacists of targeted antibiotics, daily phone call between pharmacist and ID
physician, then physician and ID physician discussion using telemedicine for ID consult if necessary
– reduced fluoroquinolone use and ?improved susceptibility
Dos Santos et al. J Telemed Telecare 2013Yam et al. Am J Health Syst Pharm 2012
what does this mean for smaller institutions?
– guidelines• use TG; antibiotic, statewide guidelines (WACA) or local “big
hospital” guidelines– formulary and restriction of antimicrobials
• restricted vs unrestricted antimicrobials– stewardship rounds
• suitable pharmacist, suitable clinician, access to ID expertise via phone or telemedicine?
– antibiotic use• suitability of NAUSP? • point-prevalence surveys, trends, benchmarking?• hospital-wide or unit specific?• indicators?
– susceptibility reporting• to formulary antibiotics, secondary and tertiary hidden
private hospitals– different stakeholders (and customers)…..
– administrator support and funding
– stewardship committee comprising administration, ID, VMOs, pharmacist(s), ICP and/or nursing staff and RMO
– hospital or group antimicrobial policy
– role of health insurers?
– Mount Hospital (September 2013)• strong ID driver and pharmacy support• ?direct support• point-prevalence survey (surgical prophylaxis ‘dog’s breakfast’) – for standard order sets• formulary and 72-hour automatic stop orders• for stewardship rounds once or twice weekly to assess post-prescription adherence• ICU ID rounds weekly• NAUSP
barriers to implementation(Johannsson B et al. Infect Control Hosp Epidemiol Apr. 2011)
• US survey of ID physicians re ASPs– ASPs becoming more common– less likely in small community hospitals– front-end restriction most common strategy– newer programs more likely focus on back-end approaches
• primary barriers– lack of funding
– ID physicians less likely to be funded compared with 10 years earlier– high cost was most likely trigger for case review
– lack of personnel
• need for studies showing benefits in smaller hospitals due to difficulties in convincing administrators to support ASPs
NAUSP Annual Report 2012
conclusions
– antimicrobial stewardship is necessary• resistance to antimicrobials is increasing• accreditation
– comprehensive ASPs contain many different strategies and require multidisciplinary input
• determined by institutional size (resources)• support from administration is critical
– use your networks
assistance
• ID pharmacy COSP (SHPA)– email discussion group
• ACSQHC• ASA
• annual pharmacist workshop
• CHRISP• WACA (WA Committee for Antimicrobials)• others
• international guidelines and literature– IDSA/SHEA/CDC– UK: Antimicrobial Stewardship: Start Smart then Focus: ARHAI
