antimicrobial stewardship
DESCRIPTION
Antimicrobial Stewardship A Global Solution!TRANSCRIPT
This presentation was presented at
Apollo International Forum on
Infection Control (AIFIC’ 2013),
Chennai
The presentation is solely meant for
Academic purpose
Antimicrobial Stewardship
Different Challenges need Different Solutions
Columbus, Ohio USA
The Ohio State University Medical Center
• James Cancer Center 165 beds bone marrow transplants & oncology
• Ross Heart Hospital 130 beds Heart and lung transplants
• The Ohio State University Hospital 850 beds solid organ transplant, General Medicine Surgery, SICU, MICU, NICU, Burn unit
Antimicrobial Resistance: A Global Problem
Antimicrobial Stewardship: A Global Solution!
MDRO are a plane ride away!
Examples: NDM-1,KPC, ESBL, Tuberculosis
Antimicrobial Stewardship
A Global Solution!
Why Stewardship? HAI’s: significant morbidity, mortality and costs
100,000 deaths annually $4.5 to 5.7 billion patient care cost
Transmission occurs most often via contaminated hands of HCW
Negative publicity for the hospital (patient safety issue)
The Ohio State Football Stadium holds 105,000 people
Stewardship: A team approach
Challenges and Barriers in India
• Lack of ID trained physicians and
pharmacists
• Lack of funding
• Open access to antibiotics
• Generics
What are USA patient’s reading?
Ref: Wall Street Journal January 2013
What works What Doesn’t
Social competence
Do you enjoy interacting with others?
Socially challenged
Prefer to work alone
Needs to be liked by everyone
Avoids conflict at all costs
Technical competence
Are you an ID expert?
Can you lead a team?
Technically challenged
Hopes others on the team will do the work
Implementation of ASP should be conceived as a
process of cultural and system change for the hospital
If the team does not possess the change management
competence, it may be necessary to involve external
experts
Excited to change
Frustrated at the thought of change
What Works What Doesn’t Work
Organizational Capacity for Change
• Trustworthy leadership Do MDs know/trust the steward?
• Capable Champions Are efforts led by people with interpersonal communication and leadership skills?
• Accountability Does ASP have a clearly defined role and responsibility? Are there consequences for non-compliance?
• Involved Management Do they support the program and connect with leadership? Judge WQ et al. Journal of Business Research. 2005;58:893-901.
What works: Define the Stewardship activities
What activity will be performed… Examples
IV to PO
Kinetic dosing of antibiotics
Authorization of restricted antibiotics
Feedback for targeted antibiotics
By what personnel…. Dedicated pharmacist
Physician
Residents or students
With what frequency… Mon-Friday
7 days a week
24/7
With what authority… Protocols for IV to PO
Kinetic dosing protocol
Communication of recommendation via
chart
What works? Pick the low hanging fruit
IV to PO conversion
Double anaerobic therapy
Broad spectrum antibiotics > 3 day and proton pump inhibitors
(increase risk of C. difficile)
Vancomycin > 3 days and no MRSA
Positive blood culture and no antibiotics
Thrombocytopenia and linezolid
Ref: Goff DA. et al . Clin Inf Dis 2012 55(4):587-92
Insist on Infection Prevention Strategies
• Provide education to patients and
family members
• Provide/post medical staff
scorecards with frequency and
trends of MDRO Do physicians know the top 5 organisms in their hospitals?
• Do physicians know the rate of ESBLs, C difficile, MRSA?
Challenge
How can stewardship
control the spread of
MDRO in your hospital?
(X Represents VRE Culture Positive Sites AFTER Cleaning)
Hayden M, The Risk of Hand and Glove Contamination after Contact with a
VRE (+) Patient Environment. ICAAC, 2001, Chicago, IL.
USA and India working together to
improve hand hygiene
• Method: 17 bed ICU used remote video
auditing with feedback
• Auditors in India viewed live video of HCW
in a US hospital performing hand hygiene
• Each observation was assigned pass/fail
Ref: Armellino D et al. 2012 Clin Inf Dis 54(1) 1-7.
Results 60,542 observations
• Pre-feedback hand hygiene rates 6.5% (3.5%-9.8%) by remote 24/7 observation
• Post-feedback
30.8% the first few weeks
87.9% with light-emitting diode boards
Message Posted on LED boards
Black Light Marker • Fluorescent marker
– An invisible gel that glows under blacklight
– Applied to surfaces in over 40 US hospitals
– An inert, safe, and unreactive substance
Without black light
Ref: Carling PC. Clin Infect Dis 2006;42(3):385
Challenge How can you control the spread of MDRO in your hospital?
Solutions 1. Novel technology
2. Empower patients* (only 14% of patients feel comfortable asking their MD/RN to wash their hands)
Ref *2012 ICHE Ottum 33(12)1282-4,
3. Identify patient s at high risk for MDRO Ref: Han et al. 2012 ICHE;33(12) 1242-5
4. Chlorhexidine bathing 70% decline in CDI with daily bathing
Ref: Rupp et al. 2012 ICHE;33(11):1094-1100
Stewardship in Limited
Resource Hospitals around
the world
Stewardship in S. Africa
Challenges: 3 ID physicians for all of S Africa, lack of funding,
pharmacist are not ID trained, some public hospitals do not have sinks
Stewardship and S. Africa • Implemented Feb 2012
• Dedicated “champions” across S.
Africa (physicians, infection control practitioners,
pharmacists, microbiologists)
• Collaboration between public and
private hospitals, administration and
government
Stewardship and S. Africa • Projects
iv to oral
de-escalation
implementing antibiograms
• Education
12 enrolled in on-line certification program in US
• email communication
• Conference calls, Facetime, Skype
• Integrate “apps” to educate providers
Outcomes of Stewardship • S. Africa
successful conversion of IV to PO
therapeutic vancomycin levels
develop antibiogram
• Dubai
ICU improve “Hang-time” of antimicrobials
• Serbia developed a “team” to identify how to utilize
micro data to guide empiric use of antibiotics
Antimicrobial Stewardship Management of
Infections : Beyond the Costs of Antimicrobials
Ref: Goff D. et al. Inf Dis Special Ed. 2012 15:35-46
Antimicrobial Stewardship Management of
Infections : Beyond the Costs of Antimicrobials
Ref: Goff D. et al. Inf Dis Special Ed. 2012 15:35-46
Challenge
How does stewardship
impact patient care?
Clinical Outcome Measures Can you show improvement in clinical outcomes?
• Reduced LOS Bauer K., Goff D. Clin Inf Dis 2010; 51(9):1074–1080
Fishman N. Am J Med 2006;119 (6 suppl 1) S53-S61
Gentry CA AM J Health Syst Pharm 2000;57(3) 268-74.
• Better patient outcome Bauer K., Goff D. Clin Inf Dis 2010; 51(9):1074–1080
Fishman N. Am J Med 2006;119 (6 suppl 1) S53-S61
White A. et al Clin Inf Dis 1997;25:230-9.
• Decreased inappropriate use Gandhi T. Crit Care Med 2010;38(8 suppl) S315-323
Apisarnthanarak A. Clin Inf Dis 2006;42(6) 768-775
What works: Technology and Education
• ASP certification program in USA MAD-ID Making a Difference Infectious Diseases international online program
S. Africa, Singapore, Canada, Saudi Arabia, Australia
http://mad-id.org
• Free apps from the Apple store Idpodcasts Weekly podcasts on ID topics
• Free webinars and handouts
ASHP American Society of Health Systems Pharmacists
www.LeadStewardship.org
• http://www.cdc.gov/getsmart/specific-groups/hcp/index.html
free handouts, brochures, powerpoint slides on ASP
So what can you do?
• Start now
• Collaborate
• Identify key leaders to develop guidelines
(based on national guidelines, tailored to your institution)
• Consequences for non compliance?
• Educate (telemedicine programs) School of Telemedicine and
• Biomedical Informatics, Sanjay Gandhi Postgraduate Institute of Medical Sciences
Lucknow, India.
• Patient’s lives depend on effective stewardship
Stewardship