Antimicrobial Stewardship

St. Mary’s Hospital

Infection Control Committee
What is Antimicrobial Stewardship
• An interdisciplinary team dedicated to
practices that improve appropriate selection,
dosing, route, and duration of antimicrobial
therapy
• The ultimate goal of antimicrobial stewardship
is to improve patient care and health care
outcomes
 Antimicrobial Stewardship Team
• Infectious Disease Physician
• Clinical Pharmacist
• Clinical microbiologist
• Information System
Specialist
• Infection control
professional
• Hospital epidemiologist
• Leadership support
 Elements of an Antimicrobial
Stewardship Team
• A comprehensive program will include:
– Active monitoring of resistance
– Fostering of appropriate antimicrobial use
– Collaboration with an effective infection control
program to minimize secondary spread of
resistance is considered optimal
 Elements of an Antimicrobial
Stewardship• Program
Education
• De-escalation of therapy
• Prospective audit with
• Dose optimization
intervention and feedback
• Conversion from parenteral
• Formulary restriction and to oral
preauthorization • Computer
• Guidelines and clinical Surveillance/Decision
pathways Support
• Antimicrobial cycling • Microbiology Laboratory
• Antimicrobial Order Forms
• Monitoring of progress and
outcome measures
 Prospective audit,intervention,and
feedback
• Have the clinical • Focus on one floor for
recommendations
pharmacist on the floor
• Up to a 37% reduction in the
making number of days of
recommendations inappropriate antibiotic
about appropriate use.Approx. $400.00 cost
savings per patient
antibiotic, route, length
• While assessing patients for
of therapy probiotics look at de-
• Probiotic Protocol to escalating of antibiotics
prevent C. Diff • Decrease rate of C. Diff
 Formulary restriction and preauthorization
• Restriction
requirements for specific of
agents
Vancomycin and third
• Control of certain antibiotic generation
use through Pharmacy and cephalosporins in
Therapeutics Committee response to VRE has
can be very effective demonstrated mixed
• Control of Cleocin use has results
led to prompt cessation of
nosocomial outbreak of C.
Diff
 Education
• Conference Presentations
• Student teaching
• E-mail alerts
• Provision of written
guidelines
• Peri-operative area order
forms
• Share results of audits
Guidelines and Clinical Pathways
• Implementation of guidelines
incorporating local microbiology
and resistance patterns
• Balance antibiotics in HAP and
VAP patients
• Use algorithms incorporating the
clinical pulmonary infection score
• Leads to decreased duration of
therapy,decreased VAP
recurrence, decrease of multi-
drug resistance patterns
 Antimicrobial Cycling
• Slows spread of
resistance
• Most popular is
Gentamicin to Amikacin
• Ceftazadime for
Ciprofloxacin lead to a
decreased incidence of
VAP
Antimicrobial Order Forms
• Use of Peri-operative
prophylactic order forms
with automatic stop at 2
days (SCIP Guidelines)
• Pneumonia Order set
(Pneumonia core measures)
with 6 different pneumonia
indications and drugs
• Order forms facilitate
implementation of practice
guidelines
 Streamlining or De-Escalation of therapy
• Continuing excessive broad therapy contributes to the selection of
antimicrobial resistant pathogens
• When culture results become available we can streamline or de-escalate
antimicrobial therapy to more targeted therapy that decreases
antimicrobial exposure and contains cost
• This can also lead to avoidance of redundant inpatient antibiotic- days
 Dose Optimization
• Dosing that accounts for
individual patient
characteristics
(age,weight,renal function)
• Site of infection
• Pharmacokinetics -Vancomycin
and aminoglycosides
• Optimize antimicrobial
pharmacodynamics of the
drugs B-lactams and
fluoroquinolones
Conversion from parenteral to oral
therapy
• Having a systematic plan for
switching from parenteral to
oral treatment may have an
added benefit of aiding in
early hospital discharge
planning
• Development of clinical
criteria and guidelines
allowing conversion can
facilitate implementation.
 Computer Surveillance / Microbiology
• Add cost codes to • Actively involved in
antimicrobial susceptibility resistance surveillance
data
• Antimicrobial report to
• Update antibiogram
pharmacy annually
• Vancomycin • Make easily accessible
dosing/utilization sheet to physicians
• Review antimicrobial errors
• Leap frog to CPOE
 St.Mary’s Antibiotic Stewardship
Efforts to Date
• Probiotic Protocol
• Antibiogram on line
• Pneumonia Order sets
• Pharmacokinetics
• Peri-op Area Guidelines
• IV to PO conversion
• Culture results from lab
• Pharmacy/IS generated
pneumonia vaccine program
What does our future hold for Antibiotic
Stewardship

• Assign antibiotic rounds to

new pharmacy school
professor ( de-escalating and
streamlining)
• Follow culture results from
lab
• Approve IV to PO conversion
automatic by pharmacist
• Finish 6 month Probiotic
study
• Work on Vancomycin Order
form
 Antibiotic Stewardship 2013
140 18.5
120
18
100
80 17.5

60
17
40
16.5
20
0 16
14

4
4

4
14

4
-1

15.5
l-1
-1

-1
-
n-

ay
ar

ov
p
Ju
Ja

Se
M

1stQtr 2ndQtr 3rd Qtr 4th Qtr

#Interventions TARGET
Athens cost per discharge
% Acceptance
Total Savings 2013 $15,458
 Documentation of Interventions by type

MONTH : SEPTEMBER 2013

Total Antibiotic Interventions:100
Percent Accepted: 85%

  Change Change IV to PO Discontinue Add an Renal Streamline Other: Probiotic

Dose Antibiotic conversion Therapy antibiotic dosing

Accepted 1 10 21 28 1 15 2   8
 
 
 

Not   5 6 3 1        
accepted    
 
 

Total 1 15 27 31 2 15 2   8

• April Ecker and Gin Fleming (Antibiotic Pharmacist)

 C.H.E. Act Initiatives Thru September 2013
Anti-infectives Anticoagulants
25 (Antibiotics) 7
6
20 2011-2013 Target
5
Target
15 4

10 Cost per 3 Anticoag cost per

adjusted adjusted discharge
2
5 discharge
1
0 0
Mar- Apr- M Jun- Jul- A Sep- Oct-
13 13 ay- 13 13 ug- 13 13
13 13

Asthma Drugs Proton Pump

9

8
1
Inhibitors
0.95
7

6 0.9
Target TARGET
5
0.85
4 Asthma Drugs Cost per PPI COST PER ADJUSTED
adjusted discharge DISCHARGE
3 0.8
2
0.75
1

0 0.7
Mar- Apr- May- Jun- Jul- Aug- Sep- Oct-
13

3
12

12

3
2

12

13
-1
-1

-1
-1

l-1
-

p-

v-

n-

p-
ar

ar
ay

ay
l

13 13 13 13 13 13 13 13
Ju

Ju
No
Se

Ja

Se
M

M
M

M
 ACT-Medication Management
Anti-Infective Stewardship Initiative
2010
$30.00
$25.00 2010 Target

$20.00
$15.00
$10.00 Cost per adjusted
discharge
$5.00 St. Mary's 2010
$0.00 Target