Antimicrobial Stewardship

Carrie Poteete MLS(ASCP)cm

Objectives

• Explain the problem

• Define Antimicrobial Stewardship

• Discuss PCAST

• Explain the presidential executive order

• Discuss what other states are doing

• Discuss what is currently being done in Kansas

Threat Report-Current state of affairs

• Issued September 16, 2013 using data from at least 10 states

• Threats were assessed according to seven factors related to resistant infections• Health impact• Economic impact• How common is the infection• 10-year projection of how common it

will become• How easily it spreads• Availability of effective antibiotics• Barriers to preventionhttp://www.cdc.gov/drugresistance/threat-report-2013

Urgent Threat

• Clostridium difficile • Carbapenem-resistant Enterobacteriaceae (CRE) • Drug-resistant Neisseria gonorrhoeae

http://www.sciencetimes.com/articles/688/20141012/treating-c-diff-infection-with-oral-frozen-encapsulated-fecal-material.htm

http://blog.labplanet.com/2012/01/27/antimicrobial-sensitivity-testing/

Serious Threats

• Multidrug-resistant Acinetobacter

• Drug-resistant Campylobacter

• Fluconazole-resistant Candida (a fungus)

• Extended spectrum β-lactamase producing Enterobacteriaceae (ESBLs)

• Vancomycin-resistant Enterococcus (VRE)

• Multidrug-resistant Pseudomonas aeruginosa

• Drug-resistant Non-typhoidal Salmonella

• Drug-resistant Salmonella Typhi

• Drug-resistant Shigella

• Methicillin-resistant Staphylococcus aureus (MRSA)

• Drug-resistant Streptococcus pneumoniae

• Drug-resistant tuberculosishttp://www.webmd.com/skin-problems-and-treatments/understanding-mrsa

Concerning Threats

• Vancomycin-resistant Staphylococcus aureus (VRSA) • Erythromycin-resistant

Group A Streptococcus • Clindamycin-resistant Group

B Streptococcus

www.examiner.com

Threat report-Key points

2 million

23,000

250,000

14,000

$20 billion

$35 billion

50%http://www.clipartbest.com/

What is stewardship?

• “Antimicrobial stewardship refers to coordinated interventions designed to improve and measure the appropriate use of antimicrobials by promoting the selection of the optimal antimicrobial drug regimen, dose, duration of therapy, and route of administration.”

• “Antimicrobial stewards seek to achieve optimal clinical outcomes related to antimicrobial use, minimize toxicity and other adverse events, reduce the costs of health care for infections, and limit the selection for antimicrobial resistant strains” –IDSA

http://www.idsociety.org/Index.aspx

Elements of Stewardship

•Prospective audits• Interventions•Feedback

PRESIDENT’S COUNCIL OF ADVISORS ON SCIENCE AND TECHNOLOGY – (PCAST)

GOALS (July, 2014)

Welcome to the President's Council of Advisors on Science and Technology, known as PCAST.

https://www.whitehouse.gov/administration/eop/ostp/pcast

The PCAST report focuses are 3 main area:

1) Improving surveillance of the resistant bacteria

2) Increasing longevity of current antibiotics

3) Increasing the rate in which new antibiotics and other inventions are discovered and delivered

http://antibiotic-action.com/aa-resources/

Second Recommendation

Effective surveillance and response for antibiotic resistance

• Strengthen state and local public health infrastructure

• Increase funding• Establish a national surveillance system for

resistance based on genomic analysis

http://www.philly.com/philly/blogs/public_health/Taxes--thats-right-new-taxes--for-public-health.html

Sixth Recommendation

Improve stewardship of existing antibiotics in the health care setting

• CMS should put reimbursement incentives into place

• Government funding requirements to drive stewardship

• Government should lead by example

https://www.cms.gov/

http://www.va.gov/

Barriers to Stewardship

Higher priority clinical initiatives

Staffing concerns

Insufficient funding

https://bobsnewheart.wordpress.com/2014/10/31/the-greatest-threat-to-your-health/

Presidential Executive Order

https://www.whitehouse.gov/about/inside-white-house

Goal 1

Slow the Emergence of Resistance Bacteria

and Prevent the Spread of Resistant Infections

http://howshealth.com/antibiotic-resistance

Goal 1

• Implement public health programs for reporting resistance• Foster stewardship

programs in all healthcare settings as well as the community

http://www.microbioncorp.com/who-report-reveals-global-antimicrobial-resistance-warning/

Goal 1

• Education to inform clinicians and the public about stewardship• Support public health departments in establishing antimicrobial stewardship programs

Goal 1

http://www.ltlmagazine.com/article/groups-commit-responsible-antibiotic-use

• Expand collaborative efforts annual reporting

• Implement annual reporting of antibiotic use

• Develop and pilot new interventions

Goal 2

Strengthen national

one-health surveillance

efforts to combat

resistancehttp://epi.ufl.edu/onehealth/news/

Goal 2

• Create regional public health lab network • Develop the Detect Network of AR Regional laboratories

http://www.google.com/imgres?imgurl=https://lh3.googleusercontent.com/-tqEj5Lo0LdE/AAAAAAAAAAI/AAAAAAAAAAA/K1b6-_tt9q8/s0-c-k-no-ns/photo.jpg&imgrefurl=https://plus.google.com/u/0/103851806558654155503&h=500&w=500&tbnid=-621rCOxqyHHkM:&tbnh=160&tbnw=160&usg=__BqncLM8CvAWhac3-hhLdBfr15OQ=&docid=k4p7Z5aA8YOO7M&itg=1

Goal 2

http://wrair-www.army.mil

• Formally recognize the Multi-Resistant Organism Repository and Surveillance

Network

Goal 2

• Link data on susceptibility testing to make it available to local, state, and federal health authorities• Submit measures to the National Quality Forum

How do we know stewardship works?Decrease resistant infections:

Tertiary care teaching hospital in the surgical and trauma ICU, Charlottsville, VA, USA

Instituted an abx cycling program

Significant reductions in the incidence of:• Antibiotic-resistant GPC

infections 7.8/100 vs. 14.6/100 • Antibiotic-resistant GNR

infections 2.5/100 vs. 7.7/100 • Mortality associated with

infection 2.9 deaths/100 vs. 9.6 deaths/100

500-bed university affiliated community hospital, Queens, NY, USA

Adopted a Restriction based program restricting routine cephalosporin use and requiring primary team to seek ID approval for use

• 80.1% reduction in hospital-wide cephalosporin use

• 44% reduction in incidence of ceftazidime-resistant Klebsiella infection and colonization throughout the hospital

• 70.9% reduction in all intensive care units

• 87.5% reduction in SICU

How do we know stewardship works?Decrease C. difficle infections:

683-bed, secondary/tertiary-care hospital, Sherbooke, Quebec, Canada

• Developed guidelines for decreasing antibiotics use associated with Clostridium difficile infections –

• Creation of educational materials for physicians and pharmacists.

• Created recommendations to suggest alternative antibiotics for treating conditions.

• Recommended shorter treatment duration for certain conditions based on IDSA’s guidelines.

• C. diff incidence decreased 60% between 2003-2004 and 2005-2006,

• Total and targeted antibiotic consumption decreased 23% and 54% respectively.

How do we know stewardship works?Decrease Cost:

545-bed, state-supported, tertiary-care teaching hospital, Jackson, MS, USA

Established restrictions on use of 2nd generation cephalosporins and aminoglycosides requiring obtaining pharmacy approval before drug disbursement

• Second generation cephalosporin use decreased 52.2%,

• tobramycin decreased by 75.9% while unrestricted gentamicin increased 229%

• Reduced expenditures on injectable antibiotics by $193,172.06 during 12 months following restrictions.

175-bed, tertiary-care children's hospital, Baltimore, MD, USA

Implemented Electronic Monitoring to provide automated clinical decision support, facilitate approval and allow real-time communication with prescribers related to antibiotics.

• Reduction in $370,069 in projected, annual cost associated with restricted antimicrobial use

• 11.6% reduction in doses of restricted antibiotics over one year.

• User satisfaction improved from 22% to 68% and from 13% to 69% among prescribers and pharmacists respectively.

How do we know stewardship works?Decrease use:

689-bed tertiary care teaching hospital, Omaha, NE, USA

Created an order form for surgical antimicrobial prophylaxis   Form use was mandatory but had an "opt out" space on it

• Increase in patients receiving appropriate antibiotics following intervention (84.9% from 62.3%),

• Significant improvement in appropriate dosing of antibiotcs for weight (89.9% from 62.1%),

• Significant increase in appropriate duration of prophylaxis (89.1% from 77.8%). 

• Mean cost of antimicrobial prophylaxis decreased to $40 per patient from $46 per patient

California

https://www.google.com/search?q=california+public+health&biw=1477&bih=730&source=lnms&tbm=isch&sa=X&sqi=2&ved=0CAgQ_AUoA2oVChMI95ukqc_MxwIVCdOACh3XIwar&dpr=1.3#imgrc=yG7OrxEoNosgYM%3A

http://cafrino.com/california-online-poker-bill-passes-through-committee/

Michigan

https://www.google.com/search?q=michigan&biw=1477&bih=730&source=lnms&tbm=isch&sa=X&sqi=2&ved=0CAcQ_AUoAmoVChMIytmfmdHMxwIVh9KACh2Kvgic#tbm=isch&tbs=rimg%3ACYUZloq2yxYGIjgbHTtzF-BWlmhR5sK_1etjEpXIJXXXzEhixoCiJ4Xf6gBzjyIbIvD-Y8gNgzYKOFT5ru-jpBnvaCSoSCRsdO3MX4FaWEV8I0x1gH2EBKhIJaFHmwr962MQRmYA7w_1rrm1EqEgmlcglddfMSGBGWVrtYiBCCqioSCbGgKInhd_1qAERUljXMkwmzcKhIJHOPIhsi8P5gRP6WXT6tVhnMqEgnyA2DNgo4VPhGodnpEVGeGWCoSCWu76OkGe9oJEfxucxPbD7qV&q=michigan&imgrc=hRmWirbLFgayXM%3A

http://www.mi-marr.org

Oregon

https://public.health.oregon.gov/PreventionWellness/SafeLiving/AntibioticResistance/Pages/GetAwarePublications.aspx

http://www.usa4kids.com/flags/Oregon.html

http://www.50states.com/flag/ksflag.htm#.VeDJO3BRHF4

http://www.kansas.gov/

https://www.google.com/search?q=kansas&biw=1477&bih=730&source=lnms&tbm=isch&sa=X&sqi=2&ved=0CAcQ_AUoAmoVChMIydzQ1tTMxwIVgriACh3jUQyp#tbm=isch&tbs=rimg%3ACYJkZ-7wPKUbIjg5XBukublhpkNAsreWSQcFm5DqxxOzwy3CGNqIBP7_14s8O4aOrT2tPyfxoaHQ1xY1uoLY_1zR18XSoSCTlcG6S5uWGmEfm2chNgYFWoKhIJQ0Cyt5ZJBwURcNMGYf_16mm0qEgmbkOrHE7PDLREJ6nt2AZ5EBioSCcIY2ogE_1v_1iEeOEGcqVq2PgKhIJzw7ho6tPa08RD7crgqb8gR4qEgnJ_1GhodDXFjRGxB7-tDreRmioSCW6gtj_1NHXxdEcah1YetPHhj&q=kansas&imgdii=zw7ho6tPa0_vrM%3A%3Bzw7ho6tPa0_vrM%3A%3BlCCnOvl5Ua6azM%3A&imgrc=zw7ho6tPa0_vrM%3A

Where can Kansas go from here?

Track antibiotic use and resistance patterns

Establish policies and guidelines for antibiotic

use

Educate and Evaluate

Provide feedback

Thank You!

http://eideard.com/2014/10/10/antibiotics-stewardship-reduces-rate-of-hospital-readmission-for-children/