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Flushing Hospital Medical Center. Antimicrobial Stewardship Program Presented by: Judith Fine, MSc, MPH, M(ASCP); Director of Infection Control. Rehana Jamali, PharmD Medication Safety Officer Flushing Hospital Medical Center. Flushing Hospital.

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Flushing hospital medical center

Flushing Hospital Medical Center

Antimicrobial Stewardship Program

Presented by:

Judith Fine, MSc, MPH, M(ASCP); Director of Infection Control

Rehana Jamali, PharmD

Medication Safety Officer

Flushing Hospital Medical Center

Flushing hospital

Flushing Hospital

  • Local Community Hospital incorporated since 1884.

  • Certificate of Occupancy:

  • Med Surg beds

  • ICU beds; Medical/ Coronary/ Surgical/ NICU.

  • Percentage of Medicare/ Medicaid NH patients 70-80%

  • Scope of services rendered:

  • Pediatrics, Maternal Child, Level III NICU, Med/ Surg, Geriatrics, Continuum of Care; TCU, Hospice.

  • High Bioburden- community onset ( NH) MDRO incidence

  • High Foreign born patient population.

Antimicrobial stewardship committee members

Antimicrobial Stewardship Committee Members


  • Deborah Asnis, MD, Chairperson, Director Infectious Disease

  • Peter Barra, MD, Medical Director, Administration

  • Zeinab El Boghdadly, MD, Resident PGY3, Medicine

  • Roseann Ciuffo, MD, Physician, Infectious Disease

  • Robert Crupi, MD, Chairman, Emergency Room

  • Raffaela Dellino, R.Ph., Supervisor, Pharmacy

  • Jaime Devera, RN, Assistant Director, Nursing

  • Esra Fakioglu, MD, Pediatric, Infectious Disease

  • Catherine Ferrari, RN, Administrator, Administration

  • Judith Fine, MSc, MPH, M(ASCP) Director, Infection Control

  • Minerva Garcia, Supervisor, Microbiology

  • Tae Hahn, R.Ph, MS, Pharm D, Assistant Director, Pharmacy

  • Rehana Jamali, Pharm D, Medication Saftey Officer, Medisys Informatics

  • Alexander Kintzoglou, MD, Chairman, Medicine, Dept. of Medicine

  • Kelly McGuire, RD, CDN, Clinical Dietitian, Nutrition

  • Siamack Nemazie, Cheif Medical Informatics Officer, Medisys Informatics

  • Martha Niederland, MD, Chairwoman, Pathology

  • Ruben Silvestre, RN, Director, Nursing Administration

  • Iqbal Tak, Physician, Infectious Disease

Ast program

AST Program

  • Aim to promote rational antimicrobial prescribing with the goal of reducing the incidence of Multi-Drug Resistant Organisms (MDROs) infections

  • Correlation between antibiotic prescribing patterns and antibiotic resistance

  • Optimize the selection, dose, duration, and route of therapy with the most appropriate drug for the patient’s condition

  • Recommendations: use an alternative therapy, de-escalate to an oral alternative, or to use no therapy, when necessary

Ast program1

AST Program

  • Strategies:

    • Antibiogram published annually – local antibiotic susceptibility data, selection of empirical antibiotic therapy only

    • Monitor restricted antibiotics – initial orders, dosing, duration, de-escalation based on C&S results or discontinuation, dose adjustments based on renal function

    • Guidelines

      • Renal function assessment – creatinine clearance calculation

      • Clostridium Difficile Infection management

    • Antibiotic Order Sets

    • Education

    • Outcomes

      • Reduction in Adverse Drug Events

      • Antimicrobial Resistance

      • Reduce Length of Stay – IV to PO conversion program

      • Cost containment

2012 antibiogram

2012 Antibiogram

2012 antibiogram1

2012 Antibiogram

Utilization and cost

Utilization and Cost

Mdro resistance patterns e coli cre

MDRO resistance patternsE.coli CRE

Mdro resistant patterns k pneum cre

MDRO resistant patternsK.pneum. CRE

C difficile annual comparison

C. Difficile annual comparison

Antimicrobial stewardship program gap analysis

Antimicrobial Stewardship Program Gap Analysis

  • Antimicrobial Use Data

  • Microbiology DataAdministration/Informatics/Medical Staff

  • Stewardship Strategies

  • Data collection

  • Best Practices

  • Determine Defined daily dose calculation for certain antibiotic and report it on a monthly basis Look for trends on a monthly basis for any significant variances in units purchased and dollars spent

Antimicrobial stewardship program gap analysis1

Antimicrobial Stewardship Program Gap Analysis

  • IV to PO Conversion Program

  • Antibiotic Restrictions

  • Renal dosing adjustments

Empiric antimicrobial guidelines diagnosis driven clinical syndromes

Empiric Antimicrobial guidelinesDiagnosis driven/ clinical syndromes

  • CAP( Community Acquired Pneumonia )

  • HCAP (Health care associated Pneumonia)

  • Complicated Skin and Skin Structure Infection

  • ComplicCNS infection (meningitis/Encephalitis)ated Urinary Tract Infection

  • Severe Diarhhea suspected C.diff

  • ( previous Hx, NHR, Hx of antibiotics, immunosuppressed)

  • Septic Arthritis

  • Antibiotic order sets to be built into the Electronic Medical record.

  • Order sets to document: empiric/ therapeutic/ prophylaxis as per the CMS requirements for survey preparations.

C difficile guidelines

C. Difficile guidelines

  • Clostridium Difficile Infection (CDI) Guidelines

  • Symptoms:

  • Mild to moderate C. difficile disease:

  • Watery diarrhea three or more times a day for two or more days

  • Mild abdominal cramping and tenderness

  • Severe C. difficile disease:

  • C. difficile causes the colon to become inflamed (colitis) or to form patches of raw tissue that can bleed or produce pus (pseudomembranous colitis). Signs and symptoms include:

  • Watery diarrhea 10 to 15 times a day

  • Abdominal cramping and pain, which may be severe

  • Fever

  • Blood or pus in the stool

  • Nausea

  • Dehydration

  • Loss of appetite

  • Weight loss

  • Risk Factors:

  • Recent antibiotic use

  • Age 65 years of age or older

  • Recent hospitalization, especially for an extended period

  • Nursing home or long term care facility

  • Recent chemotherapy use or suppressed immune system as a result of a medical condition.

  • Abdominal surgery or a gastrointestinal procedure

  • Inflammatory bowel disease or colorectal cancer

  • Previous C. difficile infection

  • Testing and Diagnosis

    • Testing for C. difficile or its toxins should be performed on diarrheal (unformed) stool, unless ileus due to C. difficile is suspected.

    • Testing for stool from asymptomatic patients is not clinical useful

C difficile guidelines1

C. Difficile Guidelines

  • 2 step method that uses a confirmatory test of C difficile antigen and C. difficile toxin A and

    • Enzyme Immunoassay (EIA) for C. difficile GDH antigen - highly sensitive, cannot distinguish between toxigenic and nontoxigenic strains

    • Enzyme Immunoassay (EIA) for C. difficile toxins A and B - sensitivity is about 75 percent; the specificity is high (up to 99 percent), relatively high false negative rate since 100 to 1000 pg of toxin must be present for the test to be positive

  • Polymerase Chain Reaction (PCR) testing - highly sensitive and specific, potential for false positive results

  • Repeat testing during the same episode is diarrhea is discouraged.

  • Colon examination - flexible sigmoidoscopy to detect areas of inflammation and pseudomembranes

  • Imaging tests - CT scan

  • Isolation/Infection Control

    • When to initiate isolation?

    • When to discontinue isolation?

    • Who can write orders for it?

  • Clinical Pathway for CDI

  • Order only 1 C. difficile assay

  • Discontinue anti-diarrheals and unnecessary antibiotics

  • Begin empiric treatment

  • Begin Contact precautions/isolation

  • Signs and Symptoms of CDI

  • antigen (-); toxin A/B (-)antigen (+); toxin A/B (-)antigen (+); toxin A/B (+)Tests:

  • Please note that only one test should be ordered. Multiple tests should be avoided.

  • PCR testCDI present:

  • Continue contact isolation (duration is until patient does not have diarrhea for at least 48 hours)

  • Continue treatment (duration below)CDI not present:

  • Discontinue CDI isolation

  • Provider must document in chart that the diarrheal symptoms are not associated with Clostridium Difficile Infection

  • Consider discontinuing CDI treatment and investigating other causes of diarrhea

  • Signs and Symptoms improve:

  • Complete course of therapy

  • No further toxin assaysBegin therapy for severe disease

  • Obtain abdominal/pelvic CT scan No improvement of diarrhea in 5 daysPositiveNegative

  • Testing Interpretation for CDI

  • EIA assay AntigenEIA Assay ToxinInterpretationRecommendationsNegativeNegativeNo C. difficile presentDiscontinue contact isolation and treatment. No repeat testing.PositivePositiveC. difficile presentContinue contact isolation therapy. No repeat testing.Positive NegativeFalse negative toxin assay or non-toxigenic C. difficilePCR test to confirm toxigenicityTreatment Recommendations for CDI

  • Disease SeveritySupportive Clinical DataRecommended TreatmentDurationInitial episode, mild or moderateLeukocytosis with a WBC ≤ 15,000 cells/µL and a serum creatinine level < 1.5 times the premorbid levelMetronidazole 500 mg PO every 6 hours10 to 14 daysInitial episode, severeLeukocytosis with a WBC ≥ 15,000 cells/µL and a serum creatinine level ≥ 1.5 times the premorbid levelVancomycin 125 mg PO every 6 hours or Vancomycin 250 mg PO every 6 hours 10 to 14 daysInitial episode, severe complicatedHypotension or shock, ileus, megacolonVancomycin 250 mg PO every 6 hours, plus Metronidazole 500 mg IV every 6 to 8 hours Surgical interventionFirst recurrenceSame as initial episodeSecond recurrenceVancomycin in a tapered and/or pulsed regimen

  • Cellulitis treatment algorithm

    Cellulitis treatment algorithm



    • 1. Patient Population - primarily elderly patients from Nursing Home with multiple hospital admissions

    • 2. Infection Type - primarily healthcare associated pneumonia required multiple empiric antibiotics which are continued for prolonged period of time

    • 3. Physician service - primarily voluntary physicians admitting patients, lack of access for education and awareness of AST initiatives

    • 4. Structure of AST program - lack of dedicated ID physician for stewardship initiatives

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