antimicrobial stewardship david meyer pharmd clinical pharmacy manager fairmont general hospital n.
Download
Skip this Video
Loading SlideShow in 5 Seconds..
Antimicrobial Stewardship David Meyer, PharmD Clinical Pharmacy Manager Fairmont General Hospital PowerPoint Presentation
Download Presentation
Antimicrobial Stewardship David Meyer, PharmD Clinical Pharmacy Manager Fairmont General Hospital

Loading in 2 Seconds...

play fullscreen
1 / 50

Antimicrobial Stewardship David Meyer, PharmD Clinical Pharmacy Manager Fairmont General Hospital - PowerPoint PPT Presentation


  • 226 Views
  • Uploaded on

Antimicrobial Stewardship David Meyer, PharmD Clinical Pharmacy Manager Fairmont General Hospital. Objectives. Identify types of antimicrobial resistance Discuss multi-drug resistant organisms and possible treatment options Describe the basic framework of an antimicrobial stewardship program.

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'Antimicrobial Stewardship David Meyer, PharmD Clinical Pharmacy Manager Fairmont General Hospital' - breanna-blevins


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
antimicrobial stewardship david meyer pharmd clinical pharmacy manager fairmont general hospital

Antimicrobial StewardshipDavid Meyer, PharmDClinical Pharmacy ManagerFairmont General Hospital

objectives
Objectives
  • Identify types of antimicrobial resistance
  • Discuss multi-drug resistant organisms and possible treatment options
  • Describe the basic framework of an antimicrobial stewardship program
slide3

Antimicrobial Resistance

Clin Infect Dis. (2011) 52 (suppl 5): S397-S428.

antimicrobial resistance selective pressure
Antimicrobial Resistance:Selective Pressure

Mulvey M R , Simor A E CMAJ 2009;180:408-415

antimicrobial resistance mechanisms of genetic resistance to antimicrobial agents
Antimicrobial Resistance:Mechanisms of genetic resistance to antimicrobial agents

Coates A et al. Nature Reviews Drug Discovery 1, 895-910 (November 2002)

antimicrobial resistance mutation selection acquired resistance
Antimicrobial Resistance:Mutation & Selection/Acquired Resistance

Enzyme Inactivation

-lactamase production

ESBL production

Carbapenemase

New Delhi Metallo- -lactamase

Examples:

E. coli producing -lactamase or ESBL

Klebsiella producing carbapenemase

antimicrobial resistance mutation selection acquired resistance1
Antimicrobial Resistance:Mutation & Selection/Acquired Resistance

Alteration of the target site

Altered protein binding

Altered DNA enzymes

Examples:

MRSA – methicillin-resistant Staph. aureus

PBP (Penicillin binding protein)-resistant Strep. pneumo

Ciprofloxacinresistance in Mycobacterium

antimicrobial resistance mutation selection acquired resistance2
Antimicrobial Resistance:Mutation & Selection/Acquired Resistance

Decreased access to the target site

Efflux pumps - Antimicrobial is pumped out of the bacteria before it accumulates

Altered structure of outer membrane proteins or porins

Example:

Tetracycline TetK efflux in Staph. aureus

Imipenem-resistant Pseudomonas

examples of common resistant bugs
Examples of Common Resistant Bugs

CMAJ February 17, 2009 vol. 180 no. 4 408-415

multi drug resistant organisms mdros
Multi-Drug Resistant Organisms (MDROs)

Prevalent in hospitals & long-term care facilities

Not as likely to cause disease in LTCF (colonization)

Cause the same infections as non-MDROs BUT

Fewer antibiotic choices

Isolation

Increased length of stay

Increased risk of ADE

Increased mortality

= Increased $$$

mdro treatment options community acquired mrsa ca mrsa
MDRO Treatment Options: Community-acquired MRSA (Ca-MRSA)

Transmission

Contaminated hands

Skin-to-skin contact

Crowded conditions

Poor hygiene

Increased risk

Athletes, military recruits, children, Pacific Islanders, indigenous populations, men who have sex with men, animal owners, ED patients, cystic fibrosis patients, urban underserved communities, and prisoners

Clinical Microbiology Reviews, July 2010, p. 616-687, Vol. 23, No. 3

slide13
Mild-moderate infection

Doxycycline or Minocycline

Caution with susceptibility tests

Clindamycin

Trimethoprim/Sulfamethoxazole

Severe infection

Vancomycin - PREFERRED

Daptomycin (NOT for pneumonia)

Linezolid (pneumonia)

Dalfopristin/Quinupristin

Limited by ADE arthralgias

Tigecycline (cSSTI, intra-ab)

Low serum concentrations

Telavancin (cSSTI)

Ceftaroline (cSSTI)

MDRO Treatment Options: Community-acquired MRSA (Ca-MRSA)

**Use varies greatly by site of infection, refer to IDSA MRSA Guidelines 2011**

*Adjuncts: rifampin (also in combo with FQs), gentamicin, beta-lactams

Clinical Microbiology Reviews, July 2010, p. 616-687, Vol. 23, No. 3

Clin Infect Dis. (2011) 52 (suppl 5): S397-S428. doi: 10.1093/cid/cir153

Gilbert DN, et al. Sanford Guide to Antimicrobial Therapy 2011, 41st ed.

mdro treatment options penicillin resistant strep pneumoniae prsp
MDRO Treatment Options:Penicillin-Resistant Strep. Pneumoniae (PRSP)
  • Causes respiratory tract infections and meningitis
  • Resistant to:
    • Penicillin G
      • *due to alteration in penicillin-binding proteins (PBPs)
    • Variable resistance to cephalosporins, macrolides, tetracyclines, clindamycin
  • Alternatives:
    • Amoxicillin/clavulanate
    • Ceftriaxone, cefotaxime
    • Respiratory quinolones
    • Linezolid
    • Vancomycin +/- Rifampin

Am J Respir Crit Care Med ; 2005 ; 171 : 388 -416 Gilbert DN, et al. Sanford Guide to Antimicrobial Therapy 2011, 41st ed.

mdro treatment options vancomycin resistant enterococci vre
MDRO Treatment Options: Vancomycin-resistant Enterococci (VRE)

Usually Enterococcus faecium

Resistant to:

Vancomycin, Aminoglycosides, Penicillins, Quinolones

Treatment options:

Linezolid

Quinupristin/dalfopristin

Faecium only

Combination therapy recommended

Tigecycline

Daptomycin

Site Specific– Urinary Tract Infections

Nitrofurantoin

Fosfomycin

CMI 16:555,2010 Gilbert DN, et al. Sanford Guide to Antimicrobial Therapy 2011, 41st ed.

Clin Infect Dis. (2010) 51 (1): 79-84 http://emedicine.medscape.com/article/216993-treatment

mdro treatment options pseudomonas aeruginosa
MDRO Treatment Options:Pseudomonas aeruginosa
  • Resistant to:
    • Meropenem, Imipenem
  • Alternatives:
    • Possible evidence for extended-infusion carbapenems
    • Fluoroquinolones – cipro > levo
    • Anti-pseudomonal aminoglycosides (APAG)
    • Anti-pseudomonal penicillins +/- APAG
    • Ceftazidime, Cefepime +/- APAG
    • Aztreonam
    • Combos of Doripenem + Polymyxin B +/- Rifampin
    • Fosfomycin + APAG
    • Polymyxin B
    • Colistin

Lister PD, Wolter DJ Clin Infect Dis 2005;40:S105-114 Livermore DM. Clin Infect Dis 2002;34:634-40

Am J Respir Crit Care Med ; 2005 ; 171 : 388 -416 Gilbert DN, et al. Sanford Guide to Antimicrobial Therapy 2011, 41st ed.

Antimicrob Agents Chemother. 2008 October; 52(10): 3795–3800

mdro treatment options extended spectrum beta lactamase esbl producing organisms
MDRO Treatment Options:Extended Spectrum Beta Lactamase (ESBL)-Producing Organisms

Risk Factors for ESBLs in non-hospitalized patients

  • Recent antibiotic use
  • Residence in long-term care facility
  • Recent hospitalization
  • Age >65 years
  • Male
  • 34% of ESBL-producing isolates from patients with no recent health care contact

Ben-Ami R et al. Clin Infect Dis 2009;49:682-90

mdro treatment options esbl producing organisms
MDRO Treatment Options: ESBL-producing Organisms
  • Most commonly Klebsiella or E.coli
  • Resistant to:
    • 2nd/3rd generation Cephalosporins
    • Aztreonam
    • Aminoglycosides
    • Fluoroquinolones
  • Alternatives:
    • Carbapenems (some emerging resistance)
      • Ertapenem for E. coli
    • In-vitro: Cefepime, Piperacillin/tazobactam, Tigecycline
    • Colistin
    • Fosfomycin

Am J Respir Crit Care Med ; 2005 ; 171 : 388 -416 Gilbert DN, et al. Sanford Guide to Antimicrobial Therapy 2011, 41st ed.

mdro treatment options carbapenemase and new delhi metallo
MDRO Treatment Options:Carbapenemase and New Delhi Metallo
  • KPC = CRE
  • Most commonly Klebsiella or E.coli
  • NDM-1 found in water samples in India
  • Resistant to:
    • All Carbapenems
    • Aminoglycosides
    • Fluoroquinolones
  • Alternatives:
    • Tigecycline
    • Colistin
mdro treatment options acinetobacter
MDRO Treatment Options: Acinetobacter

Up and coming “superbug”

Found in soil and water

Can live on skin & surfaces for days

Predominately a colonizing organism

slide21
Therapy:

ID Consult!

Agents:

Carbapenems (building resistance as of 2005)

Susceptibility 32% to >90%

Ampicillin/sulbactam +/- Meropenem

Tigecycline - in combination only (e.g. + Amikacin)

Polymyxin B + Imipenem/cilastatin + Rifampin

Colistin

Susceptibility 55% to >80%

Other treatment therapies and combinations but Acinetobacter infections very MDRO: Mortality 20-50%

MDRO Treatment Options: Acinetobacter

Landman D et al. Arch Intern Med 2002;162:1515-20 Kopterides P et al. Int J Antimicrob Agents 2007;30:409-14

Clin Infect Dis. (2010) 51 (1): 79-84 Am J Respir Crit Care Med ; 2005 ; 171 : 388 -416

Gilbert DN, et al. Sanford Guide to Antimicrobial Therapy 2011, 41st ed.

slide22

Antimicrobial Stewardship

http://www.hhnmag.com/hhnmag/gateFold/PDF/05_2012/HHN_May2012Cover.pdf

slide23

What is an Antimicrobial Stewardship Program (ASP)

IDSA Definition

Antimicrobial Stewardship is an activity

that promotes:

– The appropriate selection of antimicrobials.

– The appropriate dosing of antimicrobials.

– The appropriate route and duration of

antimicrobial therapy.

Dellit TH, Owens RC, McGowan JE Jr et al. Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for 1. developing an institutional program to enhance antimicrobial stewardship.

Clin Infect Dis. 2007; 44:159-77

antimicrobial stewardship why
Antimicrobial Stewardship – Why?

Not much in the pipeline

Boucher et al. Clin Inf Dis 2009

world health organization who 10 x 20 initiative
World Health Organization (WHO) 10 x ’20 Initiative

Published in early 2010 by IDSA

WHO identified antimicrobial resistance as a major issue

Clin Infect Dis. (2011) 52 (suppl 5): S397-S428. doi: 10.1093/cid/cir153

Clin Infect Dis 2010;50:1081-83.

antimicrobial stewardship programs asp
Antimicrobial Stewardship Programs (ASP)
  • Plethora of literature on resistance and ASP
    • Refer to local Antibiograms for most accurate resistant patterns
  • leadstewardship.org and ASHP Educational Webinars under Infectious Diseases subsection
  • Existing Webinars
    • Summarize IDSA Guidelines (2007)
      • http://cid.oxfordjournals.org/content/44/2/159.full
    • ASP-supportive literature
    • Success stories
      • Personal & in literature
  • Our focus: Key points, focused approach, resources
purpose
Purpose
  • Optimize clinical outcomes
  • Minimize unintended consequences of antimicrobial use
    • Toxicity
    • Selection of pathogenic organisms (e.g. C. diff)
    • Emergence of resistance

2007 IDSA ASP Guidelines: Dellit TH. Clin Infect Dis 2007;44:159-77.

asp guidelines core strategies
ASP Guidelines Core Strategies
  • Core Strategies
    • Prospective audit with intervention and feedback
      • Looking at antibiotic orders as they come, adjusting per pre-set guidelines
    • Formulary restriction with pre-authorization
      • UKMC: negative impact (let first dose go thru, intervene after)
  • Supplemental Strategies
    • Education, Education, Education
    • Guidelines and clinical pathways
    • Antimicrobial order forms (CPOE systems)
    • Combination therapy
    • De-escalation
    • Dose optimization
    • IV to PO conversion
    • Antimicrobial cycling (least evidence, most controversial)

2007 IDSA ASP Guidelines: Dellit TH. Clin Infect Dis 2007;44:159-77.

ASHP Midyear 2010 CE Presentation – Antimicrobial Stewardship: Building the Case and Overcoming Barriers in your Institution

http://www.ashpmedia.org/symposia/4cpe/stewardship/

cdc methods to improve antimicrobial use
CDC: Methods to Improve Antimicrobial Use

Passive prescriber education

Standardized order forms

Formulary restrictions

Pre-authorization

Pharmacy substitution

Multidisciplinary DUE

Performance feedback

CPOE

CDC: http://www.cdc.gov/ncidod/dhqp/pdf/ar/mdroGuideline2006.pdf

guiding tenets of abx use
Guiding Tenets of ABX Use

1. Severe infection – start broad

  • Get it wrong = in trouble

2. Get it IN the patient quickly (actual administration)

  • First dose = most important

3. De-escalation of therapy is a necessity

  • Right drug = narrowest-spectrum with successful response, causing the least collateral damage

4. Treat only as long as appropriate

ASHP Midyear 2010 – Antimicrobial Stewardship: Building the Case and Overcoming Barriers in your Institution: http://www.ashpmedia.org/symposia/4cpe/stewardship/

asp team members
ASP Team Members
  • Multidisciplinary problem that cannot be solved by one person
  • Core members (eventual compensation is ideal)
    • ID MD
    • ID Pharmacist
  • Adjunct members
    • Microbiologist
    • IT/Data Specialist
    • Infection Control Professional and/or Epidemiologist

2007 IDSA ASP Guidelines: Dellit TH. Clin Infect Dis 2007;44:159-77.

roles of the team members
Roles of the Team Members
  • Physician Champion
    • Knowledgeable in Infectious Diseases
    • Willing to teach untrained Pharmacist
    • Willing to help promote cause
    • Willing to work together
    • Respected by peers
    • Able to form working relationship with hospital administrator and pharmacy director

*sometimes the largest hurdle to overcome

2007 IDSA ASP Guidelines: Dellit TH. Clin Infect Dis 2007;44:159-77.

roles of the team members1
Roles of the Team Members
  • Clinical Pharmacist
    • ID-trained or strong willingness to learn backed by a solid foundation in antibiotics
    • Helps establish program structure and protocol
    • Aids in creating and/or overseeing Antibiograms
    • Performs daily interventions
    • Continually educates medical and pharmacy staff
    • Raises pharmacy awareness and rallies support

2007 IDSA ASP Guidelines: Dellit TH. Clin Infect Dis 2007;44:159-77.

roles of the team members2
Roles of the Team Members
  • Microbiologist
    • Provides surveillance data for Antibiogram
    • Develops combination antibiotic Antibiograms
    • Reviews current diagnostic tests and investigates pros and cons of incorporating new, novel tests

2007 IDSA ASP Guidelines: Dellit TH. Clin Infect Dis 2007;44:159-77.

roles of the team members3
Roles of the Team Members
  • Infection Control and/or Epidemiologist
    • Implement/improve infection control measures
    • Collect data regarding adherence and outcomes
    • Monitor healthcare-acquired infection rates
    • Investigate local outbreaks
    • Share daily reports with pharmacist
      • Isolation due to MDROs

2007 IDSA ASP Guidelines: Dellit TH. Clin Infect Dis 2007;44:159-77.

roles of the team members4
Roles of the Team Members
  • IT/Data Manager
    • Establish method for obtaining data
    • Develop/adapt database to record interventions
    • Prepare annual reports for administrative arm
    • Aid in statistical analysis of program

*most programs lack this member and the pharmacist picks up the slack

2007 IDSA ASP Guidelines: Dellit TH. Clin Infect Dis 2007;44:159-77.

performance measures
Performance Measures
  • Essential in showing value of Stewardship program
  • Examples:
    • Antibiogram
      • Performed at least annually
    • Medication Use Evaluations (MUE)
    • Utilization/Purchasing Data quarterly
    • MDRO rates
    • Blood contamination Rates
    • Quality Measures
can this be done at smaller hospitals
Can this be done at smaller hospitals?
  • 120 bed hospital in Monroe, LA
  • ID MD, clinical PharmD, infection control, microbiologist
    • *paid MD and PharmD
  • Concurrent chart review 3 days/week (limited resources)
  • Study period = 1 year (all the way back in 2000)
  • Targeted patients
    • Multiple, prolonged, or high-cost antibiotics
  • Initial pushback from medical staff
  • 69% recommendation acceptance
  • 19% reduction in antibiotic expenditures (saved $177,000!)

LaRocco et al. CID 2003.

tier system approach
Tier System Approach
  • Different approaches for different budgets/personnel
  • Low-lying fruit
    • Start small, simple, and smart
    • Identify “Problem Child” units or antibiotics
    • Easy “wins”
    • Build ASP credibility
    • IV to PO Conversions; De-escalation of therapy; Pre-printed order sets
  • Raising awareness costs = $0
  • Improve the systems you already have in place
a few examples management of mdro in healthcare settings
A Few Examples:Management of MDRO in Healthcare Settings
  • CDC’s 4 Principles:
    • 1. Infection prevention
      • Catheters , VAP
    • 2. Accurate and prompt diagnosis and treatment
      • Etiology of infectious process
    • 3. Prudent use of antimicrobials
    • 4. Prevention of transmission
      • Hand washing, isolation, etc.
      • CDC: http://www.cdc.gov/ncidod/dhqp/pdf/ar/mdroGuideline2006.pdf
a few examples restriction vs facilitation
A Few Examples:Restriction vs. Facilitation
  • Consider Facilitation vs. Restriction
  • The goal of an ASP is NOT to limit appropriate use of antibiotics
  • More restricted antibiotics = sicker patient usually is
    • More delay
    • More pushback from medical staff
    • Mixed signal of ASP
  • The only dose proven to save lives in the first one!
    • Allow according to restriction protocol, then adjust prn

ASHP Midyear 2010 – Antimicrobial Stewardship: Building the Case and Overcoming Barriers in your Institution:

http://www.ashpmedia.org/symposia/4cpe/stewardship/

many available resources
Many Available Resources

ASHP – ashp.org

IDSA – idsociety.org

CDC – cdc.gov

CID – cid.oxfordjournals.org

Available for purchase

Sanford Guide to Antimicrobial Therapy

Johns Hopkins ABX Guide

hopkins-abxguide.org

asp why now
ASP: Why now?

1. Antimicrobial overuse/misuse affects resistance

2. Antimicrobial resistance is at unprecedented levels

3. Typically financially self-supporting

  • Although this should be a secondary goal

4. It’s the RIGHT THING TO DO

ASHP Midyear 2010 – Antimicrobial Stewardship: Building the Case and Overcoming Barriers in your Institution: http://www.ashpmedia.org/symposia/4cpe/stewardship/

what is the status of asp in your institution
What is the status of ASP in your institution?
  • Question posed by speaker at ASHP Midyear Meeting 2010
  • 10% No ASP, no plans to pursue one
  • 20% No ASP, need to establish one
  • 30% Currently discussing need for an ASP
  • 20% The ASP we have is not very effective
  • 20% The ASP we have is highly regarded
  • So if you don’t have an ASP, you’re not alone but you may be soon

ASHP Midyear 2010 – Antimicrobial Stewardship: Building the Case and Overcoming Barriers in your Institution:

http://www.ashpmedia.org/symposia/4cpe/stewardship/

barriers to establishing asps
Barriers to Establishing ASPs

1. Lack of funding

  • ASPs often function in personnel’s spare time initially

2. Shortage of adequately-trained ID MDs and Pharmacists

3. Lack of pharmacy leadership support

4. MD autonomy

5. Competition for funding

  • Money is going to go to programs that are mandated

6. Antagonistic colleagues

ASHP Midyear 2010 – Antimicrobial Stewardship: Building the Case and Overcoming Barriers in your Institution: http://www.ashpmedia.org/symposia/4cpe/stewardship/

Owens RC, Shorr AF, Deschambeault AL. Antimicrobial stewardship: shepherding precious resources. Am J Health-Syst Pharm. 2009; 66(Supp 4):S15-22

building your case
Building your Case

1. Current situation is likely costing institution unnecessary dollars

2. Clinical issues make timely program implementation compelling

3. A formal business plan is essential

4. Need to demonstrate return on investment (ROI) over a reasonable time period

ASHP Midyear 2010 – Antimicrobial Stewardship: Building the Case and Overcoming Barriers in your Institution:

http://www.ashpmedia.org/symposia/4cpe/stewardship/

conclusion baby steps
Conclusion:Baby Steps
  • Avoid making cost-reduction your #1 goal
  • Educate personnel on ASP Basics
  • Identify glaring problem areas and establish areas of improvement
  • Work on multidisciplinary development of evidence-based guidelines
    • Based on national guidelines, tailored to institution based on resistance patterns
  • Work to ensure de-escalation and antibiotic stop dates
  • Improve efficiency of pharmacy distribution system
    • Facilitation vs. Restriction

ASHP Midyear 2010 – Antimicrobial Stewardship: Building the Case and Overcoming Barriers in your Institution:

http://www.ashpmedia.org/symposia/4cpe/stewardship/

conclusion needs identified by idsa in 2011 publication
Conclusion:Needs identified by IDSA in 2011 publication
  • National Funding
  • Legislative action
  • Research and Development
    • ASPs
    • Novel Antibiotics
    • Resistance, especially as it relates to MDROs

Clin Infect Dis. (2011) 52 (suppl 5): S397-S428. doi: 10.1093/cid/cir153

asp resources
ASP Resources
  • Online Webinars
    • http://www.ashp.org/menu/Education/OnlinePrograms.aspx
    • http://leadstewardship.org/activities.php
  • ASP-specific Websites
    • Nebraska Medical Center
      • www.nebraskamed.com/asp
    • Univ. of Kentucky
      • www.hosp.uky.edu/pharmacy/AMT/default.html
    • Univ. of Pennsylvania
      • www.uphs.upenn.edu/bugdrug

Goff, DA. ASHP Advantage Newsletter. CE in the Mornings. Working Together: Implementing Interdisciplinary Antimicrobial Stewardship Programs. March 2010.