ASP CORE ELEMENTS

BUDDY NEWTON, MD

DISCLOSURES

• I have nothing to disclose

• “On the whole, the position of antimicrobial agents in medical therapy is

highly satisfactory. The majority of bacterial infections can be cured simply,

effectively, and cheaply. The mortality and morbidity from bacterial diseases

has fallen so low that they are no longer among the important unsolved

problems of medicine. These accomplishments are widely known and

appreciated…”

FAMOUS ABX QUOTES

Ernest Jawetz, noted microbiologist. 1956

• “The war against infectious disease has been won”

FAMOUS ABX QUOTES

Dr. Willam Stuart, US Surgeon General. 1969

• “The time may come when penicillin can be bought by anyone in the shops.

Then there is the danger that the ignorant man may easily underdose himself

and by exposing his microbes to non-lethal quantities of the drug make them

resistant.”

FAMOUS ABX QUOTES

Sir Alexander Fleming

Nobel Lecture

December 11, 1945

• 80% of all ABX in the USA are used in animal/food industry

• 25 million pounds of ABX are produced for human consumption annually

• 160 million courses of ABX in NONhospitalized pts annually

• 30%-50% of all hospitalized pts receive a course of ABX

• 50%-99% of antimicrobial use is inappropriate

STATISTICS ON ABX USAGE

• Treatment duration too long

• Treatment of noninfectious entities

• Colonization

• “Lasix-responsive” pneumonia

• “CYA”

• Ineffective therapy when pathogen is ID’d

• Wrong choice

• Wrong dose

REASONS FOR INAPPROPRIATE USE

•Improve patient care

• Reduce unwanted consequences of ABX overuse or misuse

• Reduction in emergence of MDROs

• Preservation of antimicrobial activity for future use

• Reduction in healthcare costs

GOALS OF ABX STEWARDSHIP

WHAT IS ABX STEWARDSHIP?

• A program or series of interventions to monitor and direct antimicrobial

use at a health care institution, thus providing a standard, evidence-based

approach to judicious antimicrobial use.

• Right drug

• Right dose

• Right duration

CDC CORE ELEMENTS OF AN ASP

1. Leadership Commitment

2. Accountability

3. Drug Expertise

4. Action

5. Tracking

6. Reporting

7. Education

LEADERSHIP COMMITMENT/ACCOUNTABILITY

• C-suite to can issue a board-approved statement supporting ASP and set up periodic

information sessions of ASP activities and outcomes to the hospital board

• Establish an ASP Committee with a charter which identifies specific responsibilities of the

committee and members

• Should be MULTIDISCIPLINARY (physicians, pharmacy, lab, admin, nursing, infection prevention, IT)

• Designate a physician (with dedicated ASP time and training) who is responsible for ASP

outcomes and can provide feedback to both C-suite and providers

• Integrate current QI/Safety activities into the ASP (“don’t reinvent the wheel”)

• Issue a commitment statement from key hospital leaders to hospital employees

DRUG EXPERTISE

• Hospital or outside support for ASP training programs (SIDP, MAD-ID)

• Dedicated ASP time with appropriate training

• IV-to-po programs

• Automatic renal dosing

• Pharmacokinetic dosing of AGs and vancomycin

• Provide individual chart review and provider feedback based on evidence-based

national practice guidelines

• Develop & monitor restricted ABX formulary

ACTION

• Develop or modify CAP, UTI, CDI, +/or SSTI order sets. IDSA guidelines readily

available and easy to set up

• Require dose, duration, and indication for all ABX orders

• Identify your most used ABX and see if evidence-based guidelines support early de-

escalation or in some cases, discontinuation

• Pharmacy review of duplicate coverage and pharm initiatives

• RN protocols for automatic C diff isolation and diagnosis

• RN ABX 48-hour “time-outs” reported to providers

ACTION (OTHER EXAMPLES)

• Develop a PPI use reduction protocol

• Develop or update an antibiogram

• Beta-lactam allergy reduction (questionnaire, PCN challenge program, PCN skin testing)

• S aureus bacteremia treatment protocol

• Vancomycin use reduction (MRSA nasal screening in PNA, AUIC dosing, PCN allergy reduction)

• Lab “stewardship” to improve testing efficiency and appropriateness

• Compliance with sepsis order sets, CMS core measure compliance, sepsis mortality rates

TRACKING• Develop and maintain an antibiogram

• Monitor ASP recommendation compliance rates and compare LOS or LOT for compliers vs noncompliers

• Monitor C diff rates and other HAIs (probably already do this via Inf Control)

• Monitor overall or specific ABX administration rates (DOT, DDD, ABX usage/pt days)

• ABX rates compared to MDRO rates (e.g.- vanco use compared to MRSA rates, carbapenem use

compared to ESBL rates, etc)

• Track adherence to facility-specific order sets for CAP, UTIs, CDI, SSTIs or policy adherence with dose,

duration, and indication

• Monitor ABX overuse during transitions of care (esp at discharge)

• Report ABX use data to NHSN (requires compatible software)

REPORTING• Report results of what you are tracking back to the C-suite, hospital board, key hospital

committees, medical staff, and hospital staff. Keep it very transparent!

• Physician champion or CMO can review provider-specific reports with individuals clinicians

(esp the “problem children”)

• Publish annual antibiograms for all staff

• If possible, join a collaborative for benchmarking and self-assessment (you’ve already done

this by being here today!)

• Presentation at periodic staff meetings or Annual Medical Staff meeting

• Newsletters, emails, posters

EDUCATION

• Collaborative webinars, newsletters, blogs, etc.

• ASP education at annual Medical Staff meetings and periodic department meetings

• Passive education with reportable items on posters, infoTVs, etc.

• Incorporate ASP education and awareness into new provider and staff orientation

and any necessary annual training

• Document education with a quiz to complete the session

• Patient/family education with specific patient stories, ABX education material, C diff

and HAIs

SUMMARY

• Compliance with the CDC Core Elements is essential to a successful ASP and

compliance with regulatory agency requirements

• Find action items that you already do or things that need to be done in order

to help streamline and standardize your common medical problems. These

can then be tracked and reported and thus lead to education.

• DON’T MAKE IT HARDER THAN IT HAS TO BE!!