Transcript Meropenem use at Royal Perth Hospital

antimicrobial stewardship
and standard 3.14…….
Matthew Rawlins
ID pharmacist
Royal Perth Hospital
September 2013
[email protected]
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 resistance
trend data, Gram-negatives % multi-resistant, community
2008-2010
AGAR 2011
10%
P=0.03
P=0.02
8.6%
9%
8%
7.2%
7%
6%
5.4%
5%
2008
4.5%
2010
4%
3.0%
3%
3.4%
2%
1%
0%
E. coli
Klebsiella
Enterobacter
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 use
front 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
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–
–
–
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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)
[email protected]
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 resistance
Ibrahim 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
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point-of-care review and interventions
knowledge and enforcement of restrictions
referral of cases
advice and education at clinical level
smaller hospitals
Septimus 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)
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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)
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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 2013
Yam 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
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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
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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