Results from Antimicrobial Stewardship (AMS) Program ... · •Level 1 Trauma Center (nationally...
Transcript of Results from Antimicrobial Stewardship (AMS) Program ... · •Level 1 Trauma Center (nationally...
Results from Antimicrobial Stewardship (AMS) Program
Implementation
Somer Smith, PharmD, BCPS, AAHIVP
Disclosures
• Consultant and speaker for Theratechnologiespharmaceutical company
Objectives
• Summarize the core elements of a hospital antimicrobial stewardship program
• Describe initial implementation strategy for an antimicrobial stewardship program and engagement of stakeholders
• Review an antimicrobial stewardship Vancomycin quality improvement strategy and outcomes
• Summarize future directions
The Medical Center - Navicent Health
• 637-bed, Not-for-Profit hospital
• Level 1 Trauma Center (nationally verified)
• Teaching Hospital (Mercer University College of Medicine)
• Beverly Knight Olson Children’s Hospital
• Location- Macon, GA
CDC Core Elements Gap AnalysisProcess Prior to 2019 Process After 2019
Leadership Commitment
Letter from CMO Updated Letter from new CMO, CMO attendance at all ASP meetings, support from CMO and Chief of Systems of Care
integration of Quality in physician newsletter
Accountability ID Physician champion, no full-time ID Pharmacists
ID physician champion and 1 FTE ID Pharmacist
Key Supporters IP, Lab, Intensivists CMO, IP, Lab, Hospitalists, Intensivists, Quality, all ID groups
Stewardship Program Functions
No formal rounds, no binder, quarterly meetings
ASP Binder, prospective audit, quarterly meetings
Guidelines None Empiric Therapy Guidelines
Interventions Restricted antibiotics, Vancomycin 72 hr de-escalation
Prospective Audit Feedback (includes review of restricted antibiotics, patients on antibiotics > 48 hrs, MDROs)
Tracking/Reporting None AUR, Top 10 Antimicrobial Expenditures, MDROs
Education Unit education by pharmacists, emails
Stewardship website, grand rounds, physician newsletter, ICU in-services, system wide emails
Methods
No dedicated prospective audit and
feedback. No dedicated pharmacist. ID physician
led policies.
January 2019:
Gap analysis and implementation of system-
wide ASP
with daily prospective audit feedback
ASP pharmacist communicates real-time
recommendations to clinicians
24 months
2016-2018
Pre- ASP Implementation
February–Current
Post-ASP Implementation
8 months
ASP Intranet Site
Example Goals for 2018 & 2019
• Decrease Vancomycin AUR by 10%
• Decrease C.diff rate
• Increase IV to PO conversion rate by10%
Vancomycin (IV)
• IDSA recommends that ASPs implement guidelines and strategies to reduce antibiotic therapy to the shortest effective duration.
• Currently, no guidelines in place at Navicent Health targeting vancomycin stewardship
• CDC recommendations for preventing vancomycin resistant organisms (VRE, VRSA)
• Guideline development should be part of the hospital's quality-improvement program
IDSA – Infectious Diseases Society of AmericaASP – Antimicrobial Stewardship ProgramVRE – Vancomycin resistant Enterococcus sp.VRSA – Vancomycin resistant Staphylococcus aureus
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Medical Center - (IV) Vancomycin Consumption
0 100 200 300 400 500
≤ 3
4 to 6
7 to 10
11 to 14
15 to 21
> 21
Patients
Da
ys
of
Th
er
ap
y
Days of Vancomycin Therapy per Patient(January - March 2018)
Annual spend on vancomycin at Navicent Medical Center: $400,000 10
Goal
• Reduce vancomycin usage without compromising care
– Target 10% reduction
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IV Vancomycin Stewardship protocol
• P&T/MEC have approved a protocol allowing pharmacists to discontinue vancomycin therapy after 72 hours in patients who do not meet one of the following criteria:– MRSA positive culture• Documented MRSA infection within previous 12 months• 2 or more positive cultures for methicillin-resistant coagulase-negative
staphylococcus • Same pathogen and source of specimen!
• Enterococcus positive culture • CNS infection • Gram-positive infections in patients with Type 1 allergy (rash, anaphylaxis) to β-
lactams• Febrile Neutropenia• Patients followed by infectious disease or intensivist
• Prescribers will be directed to consult an infectious disease specialist with concerns regarding discontinuation of vancomycin therapy
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How to Approach Patients on Day Three
Does patient meet criteria
for vancomycintherapy per
protocol?
Yes
Continue vancomycin
and clarify stop date
No
Does the patient have alternative
gram positive coverage?
YesDiscontinue vancomycin
after 72 hours
NoDiscuss with
Provider
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Monitoring and Follow-up
• Re-evaluate 6-12 months after implementation
– Evaluate safety and stewardship endpointsProcess Measures Outcome Measures
• Duration of Therapy• Days of Therapy• Compliance with protocol
• Hospital Length of Stay • Expenditures• C. difficile infections or other adverse
events related to antibiotic treatment
*Reproduced from: Barlam TF, Cosgrove SE, Abbo LM, et al. Implementing an antibiotic stewardship program: Guidelines by the Infectious Diseases Societyof America and the Society for Healthcare Epidemiology of America. Clin Infect Dis 2016; 62(10):e51-77, by permission of Oxford University Press on behalfof The Infectious Diseases Society of America. Copyright © 2016 Oxford University Press. Available at: www.idsociety.org.
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Vancomycin MUE
• 556 patients started on Vancomycin at Navicent Health during May 2019
• 212 were initial orders in the ED
• Retrospective chart review of 100 randomly selected from 212 initial orders from ED
– 14 orders excluded for patients discharged home from ED
– 86 orders included in analysis
Vancomycin MUE
Pa tie n t P o p u la t io n (n = 8 6 )
G e n d e rMa le : 4 5 (5 2% ) Fema le : 4 1 (4 8% )
A g e (ye a rs )
A ve ra g e Me d ia n Ra n g e
6 1 .2 6 3 1 8 – 8 8
Du ra tio n o f Th e ra p y (d a ys) 3 .6 3 1 -1 9
L e n g th o f S ta y (d a ys ) 9 .3 71 -3 4
Vancomycin
Empiric Treatment IndicationBacteremia
2%HAP/VAP/C
OPD Exacerbatio
n23%
CAP8%
Cellulitis/SSTI
13%DFI/DWI/Necrotizing
Fascitis8%
Sepsis33%
Osteomyelitis4%
Other9%
9%
4%
7%
41%
28%
11%
0% 10% 20% 30% 40% 50%
Catheter in place
History of MRSA colonization
Indwelling Hardware
Transfer from nursing home/subacutefacility
Recent prolonged hospitalization(<3months)
Current prolonged hospital stay(>2weeks)transfer
Risk for MRSA (n=46)
Positive Cultures (n=33)15%
13%
9% 9% 9% 9% 9%
6% 6% 6%
3% 3% 3%
Isolated Organisms
Vancomycin 72 Hour De-escalation
• 68 (79%) patients met criteria
– 54 (79%) de-escalated
– 14 (21%) not de-escalated
• 18 (21%) patients did not meet criteria for de-escalation
– 16 (89%) continued
– 2 (11%) vancomycin stopped prematurely
Vancomycin Utilization Month over Month
96.0397.57
99.94
93.38
91.46
95.99
102.51
88.97 89.25
92.23
88.07
90.47 90.64
80
85
90
95
100
105
JAN FEB MAR APR MAY JUN JUL
Day
s o
f Th
erap
y /
10
00
Day
s at
Ris
k
2018 2019
Vancomycin Utilization vs MRSA Rate
0.0
5.0
10.0
15.0
20.0
25.0
80
85
90
95
100
105
Ca
ses
/ 10
,00
0 D
AR
DO
T
/10
00
DA
R
2018-2019
VANCOMYCIN MRSA RATE Linear (VANCOMYCIN)
Top Antimicrobial Expenditures
2018
• Daptomycin $ 483,158
• Vancomycin $454,966
• Avycaz - $145,378
• Ceftaroline $119,937
• Zosyn- $ 71,837
2019 Extrapolated
• Daptomycin $ 440,814
• Vancomycin $187,894
• Avycaz - $99,476
• Ceftaroline $269,660
• Zosyn- $ 120,812
Potential barriers
• Physician resistance
– Broad-spectrum coverage = CYA coverage
– Unfamiliar or uncomfortable with practicing antibiotic stewardship
• Patient is responding to therapy
• Pharmacist resistance
– Reluctant to make recommendations to prescribers, if necessary
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Key Drivers of Existing Program Success
• Strong, engaged program and hospital leadership
• ID physician as key strategic partner
• Interdisciplinary teamwork
• 1 FTE for stewardship pharmacist
• Lab engagement
• De-centralized Clinical pharmacists
Future Directions
2018
• Daptomycin $ 483,158
• Vancomycin $454,966
• Avycaz - $145,378
• Ceftaroline $119,937
• Zosyn- $ 71,837
2019 Extrapolated
• Daptomycin $ 440,814
• Vancomycin $187,894
• Avycaz - $99,476
• Ceftaroline $269,660
• Zosyn- $ 120,812
Future Directions
• Daptomycin-– MUE completed– Prescriber prescribing
patterns– Restricted antimicrobial
• Ceftaroline-– Complete MUE– Restrict?
• Zosyn-– MUE completed– Increase in AKI rate with Zosyn + Vanc
combination– Empiric therapy guidelines and Sepsis
powerplans changed from Zosyn+Vancomycin to Cefepime+Vancomyin
• Automatic IV to PO– Consult list built in Cerner– De-centralized pharmacists to review
consult list daily
THANK YOU
Questions?