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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
  • ANTIMICROBIAL STEWARDSHIP COMMITTEE
  • 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
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
barriers
Barriers
  • 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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