antimicrobial stewardship,pharmacy

and standard 3.14……. Matthew Rawlins

ID pharmacistRoyal Perth Hospital

June 2014matthew.rawlins@health.wa.gov.au

plan

• definition

• why is there a need for stewardship?

• pharmacy and implementation of an ASP (antimicrobial stewardship program)

• getting started and ASP components

• pharmacy resources

• 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

international benchmarking

NAUSP Annual Report 2012-2013

stewardship – where to start?• ACSHC publication and executive support

• “pink book” (TG: antibiotic)– local guidelines where necessary

• antimicrobial formulary and restriction

• measuring use (before you start and as you go)– NAPS– NAUSP

• antibiograms

• rounds

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

ASP structure

antimicrobial stewardship committee (ASC)

• multidisciplinary membership– ID pharmacist

• DUE, QUM, “interested” pharmacist(s)

• role• directing appropriate antimicrobial use at institution

level

• TOR• chair/membership/reporting• aims and objectives

executive support (ACSQHC 2011)

VRE outbreak RPH 2001

provision of resources (esp. 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

strategies (ACSQHC 2011)

• front end– formulary and approval systems

• all institution except possibly ICU

• back end – review and prescriber feedback– point of care interventions

• all of institution including ICU

• outcome measures and education• measuring performance• addressing prescriber education and competency

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

• traffic light system

– antimicrobial approval system• telephone/verbal• computerised (eDSS)

– rapid and targeted review facilitated

– expert advice is available• 24 hours (on call service A/H)

measuring antimicrobial use(ACSQHC 2011)

• continuous or point-prevalence surveys– before you start and as you go– benchmarking

• international data• national (NAUSP, NAPS)• locally

– trends• within hospital

– can they be linked to particular events?» eg. increased ESBL rates

– clinical audit of particular units/guidelines

NAPS – resultsNational Antimicrobial Prescribing Survey

(www.naps.vicniss.org.au)

NAPS - resultsBENCHMARKING DATA

NAPS - results

antimicrobial use

• National Antimicrobial Use Surveillance Program (NAUSP)

vicki.mcneil@health.sa.gov.au

– Business Unit for OBDs– InfoHealth for iPharm reports

NAUSP total hospital use

NAUSP Annual Report 2012-2013

back end review of therapy - RPH

• stewardship rounds– IV to PO switch– empirical to directed therapy– cessation of therapy– duration of therapy– management advice

• assessment of clinician acceptance

• cost savings

RAD

stewardship rounds

measuring the performance of ASP’s(ACSQHC 2011)

ASR - all advice

ASA Abstracts 2014

ASR – cost savings

Cost Savings for Rounds

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ASA Abstracts 2014

antimicrobial use – cost savings

– institution (formulary decisions)– unit (guidelines containing antimicrobials)– patient level (rounds)

• compare what was done to what would have been done

– approximately $120-240 per patient (ASA Abstracts 2014)

– institution unit costs and DDD’s/patient days can be significantly reduced by an ASP (Standiford et al. Infect Control Hosp Epidemiol. 2012)

antimicrobial usemeasuring the impact

antimicrobial use time-series analysis• compare rate of increase before and after the

stewardship intervention(s)• ratio of narrow-spectrum to broad-spectrum agents

(eg. 1st/2nd versus 3rd/4th generation cephalosporins)

David Andresen ASA 2013

Ratio of Narrow Spectrum to Broad Spectrum Cephalosporins (outside ICU)

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Jul-04 Jul-05 Jul-06 Jul-07 Jul-08 Jul-09 Jul-10 Jul-11 Jul-12 Jul-13

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education and competency of prescribers (ACSQHC 2011)

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 antimicrobial use be linked to clinical outcomes? (“do no harm!”)

– 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 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 for ASR review• advice and education at patient level

IT support(ACSQHC 2011)

• measuring performance of stewardship programme» development of databases» Smart-phone/tablet applications» electronic prescribing, medical records

• eDSS– address organisational, social and cultural issues relating to

prescribing behaviour during implementation– pharmacist/AST maintenance and support

audit support– DUAG or similar– pharmacist rotations, interns, students?

smaller hospitalsSeptimus and Owens CID 2011 (Suppl)

conclusions

– antimicrobial stewardship is here• ACSQHC and accreditation

– comprehensive ASPs contain many different strategies and require multidisciplinary input

• determined by institutional size (resources)• support from administration is critical

– use your (pharmacy) networks

assistance• ID pharmacy COSP (SHPA)

– email discussion group

• ACSQHC (“the commission”)• ASA (Australian Society for Antimicrobials)

• annual pharmacist workshop

• NPS (National Prescribing Service)• NAUSP, NAPS (usage data)

• international guidelines and literature– US: IDSA/SHEA/CDC– UK: Antimicrobial Stewardship: Start Smart then Focus: ARHAI