Antimicrobial Stewardship in Hospitals Novel Strategies for Future Success

Sameer Elsayed MD, FRCPC

Infectious Diseases, Internal Medicine, and Medical Microbiology

Western University, London Health Sciences Centre, and St. Joseph’s Hospital

Disclosures

None

Outline

• Review of Antimicrobial Resistance

• Why Antimicrobial Stewardship?

• Traditional Stewardship Strategies

• Novel Stewardship Strategies

• ASP/IPAC Synergies

• Summary

Antimicrobial Resistance (AMR)

• One of the greatest public health threats in the modern era

• Significant morbidity, mortality, societal, and healthcare costs

• Limited number of new antimicrobials

• Mitigated by strategies to reduce antimicrobial prescribing• Engagement and execution remain a challenge

• Patient, prescriber, and healthcare system factors

Future AMR Mortality

Review on Antimicrobial Resistance, UK, 2014

AMR Mortality Rate: Year 2050

Review on Antimicrobial Resistance, UK, 2014

Antimicrobial Misuse

• About 50% of hospitalized patients receive at least one antimicrobial during their stay

• About 30-50% of in-patient antimicrobial therapy is considered unnecessary

• About 20% of patients experience at least one antimicrobial-associated AE

Holmes AH. Lancet 2016

Global Antimicrobial Consumption

Van Boeckel TP et al. Lancet 2014

Antibiotic Classes and CDI Risk(Brown KA, AAC May 2013)

Antibiotic Dose Response Relationship and C. difficile InfectionHengsens MPM et al. JAC. 2012; 67: 742–748

Factors Affecting Antimicrobial Prescribing

Patient Factors- sociodemographics- past experiences- expressed expectations - reported symptoms - Illness severity

Clinician Factors- sociodemographics- training/specialty- knowledge- judgment and heuristics- perceived patient expectations

System Factors- practice setting- formulary/restrictions- pharmaceutical reps

Clinician’s Decision to Prescribe Antimicrobials

Prescribing and Medico-Legal Risks

• CMPA review of cases involving antibiotic prescriptions• n = 150• 5-year period (2011 – 2015)

• Most cases of inappropriate prescribing due to incomplete patient assessment or poor clinical judgment

• Issues• Incorrect diagnosis• Wrong agent• Failure to review contraindications or drug interactions• Incorrect dose• Lack of therapeutic monitoring or patient follow-up• Lack of ID consultation for some cases

The What and Why of Antimicrobial Stewardship

• A patient safety initiative• Improved patient care through oversight of antimicrobial use in clinical practice

• Antimicrobial prescribing in keeping with:• Appropriate clinical indication

• Is the diagnosis correct?• Appropriate agent, dose, route, and duration of therapy

• Is the correct treatment being prescribed?

Accreditation Requirement

• Canada (Accreditation Canada)• Effective January 2013

• All hospitals

• Compliance ~ 63% (2014)

• United States (Joint Commission)• Effective January 2017

• All hospitals and LTCFs

Antimicrobial Stewardship: Core Elements(Adapted from Centers for Disease Control and Prevention (CDC). Core elements of hospital antibiotic stewardship programs)

• Leadership Commitment – human, financial, IT

• Accountability & Drug Expertise – ID physician, ID pharmacist

• Action – strategies

• Tracking – antimicrobial consumption; drug resistance; antibiograms

• Reporting – sharing data with relevant hospital staff members; score cards

• Education – local practice guidelines, didactic rounds

ID Physician ID Pharmacist

Microbiology

Epidemiology Information Systems

Antimicrobial Stewardship

Program

InfectionControl

Nursing

Prescribers Communication

Hospital Leadership

Minimum Staffing Requirements(Source: AMMI Canada)

• Team Members• Physician: 1.0 FTE/1000 beds• Pharmacists: 3.0 FTE/1000 beds• Administrative Support: 0.5 FTE/1000 beds• Data Analyst: 0.4 FTE/1000 beds

• Steering Committee Members• Infectious Diseases• Pharmacy• Infection Control• Microbiology• Hospital Administration• Information Technology

TRADITIONAL ASP STRATEGIES

Traditional ASP Strategies: The Big Three

• Formulary Restriction

• Preauthorization

• Prospective Audit and Feedback

Formulary Restriction

• Defined institutional formulary

• Direct control over antimicrobial use

• Minimal threat to prescriber autonomy

• Optimal strategy to deal with high-cost antibiotics

Hospital Formulary Restriction

• Agents considered include those which have:• Potential to promote resistance• Potential for misuse• Broad-spectrum activity• High cost• Risk for serious adverse effects

• Examples• Imipenem, meropenem, ertapenem, aztreonam, daptomycin, linezolid,

amphotericin B, caspofungin• Other agents to consider include fluoroquinolones, clindamycin, and

fluconazole

Fluoroquinolones

• Among the most commonly prescribed antibiotics worldwide

• Excessive use associated with increased FQ-resistant and ESBL-producing bacteria

• Exposure associated with MRSA colonization and Clostridium difficile infection in hospitals and LTCFs (Couderc C et al. CID 2014; Pitiriga V

e al. Adv Ther 2017)

• FQ restriction as an Antimicrobial Stewardship strategy

Prospective Audit and Feedback

• Physician access to (most) antibiotics is not restricted

• ASP Team members review antibiotic prescribing practices

• Feedback of recommendations if reviewed antibiotics are deemed to be inappropriate

• Avoids loss of autonomy for prescribers; creates incentives for improved performance

• Labour-intensive; less effective than formulary restriction; compliance is voluntary

Preauthorization – ID physician/ASP team

• Institutional Utilization Criteria• Prescriber indicates rationale for use

• Electronic (CPOE) or paper-based order form

• May challenge prescriber autonomy

• May result in Increased use of other antibiotics• “squeezing the balloon”

“Low-Hanging Fruit” ASP Strategies

• Selection of the most obtainable targets with limited resources• Formulary restriction

• IV-to-oral conversion

• Automatic substitutions

Intravenous-Oral Conversion

• Numerous studies demonstrate cost savings without compromising efficacy or safety

• Associated with:

• Decreased LOS

• Decreased catheter-related infections

• Reduced (pharmacy and nursing) workload

• Examples

• Fluoroquinolones

• 1st generation cephalosporins

• Metronidazole

• Fluconazole

• Linezolid

Measurement

• Process Measures

• Antimicrobial costs

• Antimicrobial consumption

• DDD/1000 patient days

• DOT/1000 patients

• Clinical (Outcome) Measures• Rates of C. difficile infection

• Antimicrobial resistance rates

• Length of stay

• Readmission rates

NOVEL STRATEGIES

“Novel” Strategies

• Education of hospital ward Pharmacists on Antimicrobial Stewardship• “Train the trainer”

• Real-Time Clinical Documentation

• Structured Clinical Pathways with Stakeholder Engagement

• Allergy Delabeling

• Diagnostic Stewardship

“Train the Trainer”

• Leveraging the power and knowledge of the team Pharmacist

• Regular communication with ASP team• Sharing of strategies

• Linkages with the Microbiology Laboratory• Secure Email communication of C. difficile results to Pharmacy Group

DATA, DATA, and MORE DATA!

Real-Time Clinical Documentation

STRUCTURED CLINICAL PATHWAYS

Antibiotic Allergy Delabeling

• Many patients with self-reported penicillin allergy are subsequently found to tolerate beta-lactam antibiotics

• Inaccurate allergy records promote increased use of suboptimal and more expensive antimicrobials with a greater risk of adverse effects

• An accurate allergy history is essential to enhance the quality of care

• Allergy records in the EMR must be updated to optimize future treatment

Diagnostic Stewardship

• Modifying the process of ordering, performing, and reporting diagnostic tests

• Pre-analytic, analytic, and post-analytic interventions

• Guidelines for appropriate test ordering

Morgan et al. JAMA. 2017;318:607-608

ASP and IPAC Programs: Similarities

• Multidisciplinary

• Accountability and Leadership commitment

• Impact on Quality of Patient Care and Safety

• Use Metrics and Track outcome measures

• Mandated in all Health Care facilities

Summary

• ASPs foster improved quality of care through judicious antimicrobial prescribing

• Engage hospital leadership in setting goals and expectations, and securing resources

• Include administrative leaders as members of the ASP

• Establish strong linkages with IPAC

• Share the impact of ASP interventions healthcare quality

• Implement proven strategies, and strive for CQI

LHSC ASP Team

• ASP Pharmacists• Rita Dhami, PharmD• Zagorka Popovski, PharmD

• ASP Physician• Sameer Elsayed, MD

• Information Technology• Suhair AlShanteer

• Microbiology• Johan Delport

• IPAC• Alice Newman

Thank You!

Forster SC. Nat Rev Microbiol 2017