Antimicrobial Stewardship and Infection Prevention: A Critical Connection October 30, 2014 Anurag Malani, M.D. Medical Director, Infection Prevention and.

Antimicrobial Stewardship and Infection Prevention:

A Critical Connection

October 30, 2014

Anurag Malani, M.D.Medical Director, Infection Prevention and

Antimicrobial Stewardship ProgramsSt. Joseph Mercy Health System

Adjunct Assistant Professor, University of Michigan

Outline

Reasons for urgency of Antimicrobial Stewardship Programs (ASPs)

Understand the purpose, goals, and provide overview of an ASP

Describe ASPs in key settings Summary and case studies

What is Antimicrobial Stewardship?

“The selection of the optimal antimicrobial agent, route of administration, dose, and duration to provide maximal clinical benefit, while minimizing unintended consequences.”

Why Antimicrobial Stewardship?

Up to 50% of abx use is inappropriate High quantity, poor quality

Inappropriate & unnecessary abx use can lead to selection of resistant pathogens

Antimicrobial resistance continues to increase Emergence of antimicrobial resistance leads to

significant impact on pt morbidity & mortality, health care costs

Dellit TH, et al. Clin Infect Dis 2007;44:159-77

Why Antimicrobial Stewardship in Long Term Care?

Implementation of ASP in LTCF has been limited U.S. population continues to age

Estimated 21% of population in 2040 > 65 y More than 15,000 nursing homes

High prevalance of colonization and infection with MDRO

Failure to control abx use in LTCF can also affect surrounding hospitals

Rhee S, et al. Infect Dis Clin N Am 2014;28:237-46

How We Acquire Antibiotic Resistant Organisms in Hospitals

Paterson DL. Clin Infect Dis 2006;42:S90-5

Resistance: A Public Health Crisis

www.cdc.gov/drugresistance/healthcare

Antimicrobial Resistance Continues to Increase

Wenzel et al. Infect Cont Hosp Epi 2008;29:1012-8

Emergence of KPC Infections

Urine Culture Result Positive for CRE

KPC-producing CRE in the U.S. - 2014

http://www.cdc.gov/hai/organisms/cre/TrackingCRE.html

Trends of Multi-drug Resistant Organisms

Antibacterials Approved by the FDA, 1983 - 2007

Spellberg B et al. Clin Infect Dis. 2008;46:155-164

Impending Crisis of New Antibiotics

Last new class of drugs active against GNB, in the 1970s, – “Trimethoprim”

No new classes of antimicrobials in the foreseeable future

No new drugs to deal with multi-resistant GNB until 2018

WHO – “Antibiotic resistance” as one of major threats to human health

1. Bartlett J. Clin Infect Dis 2011;53:S4. 2. http://www.ecdc.europa.eu/en/publications/Publications/Forms/ECDC_DispForm.aspx?ID=444.

Evolving Resistance, The“ESKAPE” Organisms

Enterococcus faeciumStaphylococcus aureusKlebsiella pneumoniaeAcinetobacter baumanniiPseudomonas aeruginosaEnterobacter species

Bartlett J. Clin Infect Dis 2011;53:S4. .

Controlling Resistance?

A combination of BOTHEffective antimicrobial stewardship

program

ANDComprehensive infection control program

Have been shown to limit the emergence and transmission of antibiotic resistant bacteria

Dellit TH, et al. Clin Infect Dis 2007;44:159-77

Antimicrobial Stewardship Works

Valiquette L, et al. Clin Infect Dis 2007;45:112-121

Impact of a Reduction in the Use of High-Risk Antibiotics on the Course of an Epidemic ofClostridium difficile-Associated Disease Caused by the Hypervirulent NAP1/027 Strain

Antimicrobial Stewardship Reduces Costs

Standiford H, et al. Infect Cont Hosp Epi 2012;33:338-46.

Clinical outcomes better with antimicrobial stewardship

program

Fishman N. Am J Med. 2006;119:S53.

Antimicrobial Stewardship Program Goals

Ensure appropriate antimicrobial use- Optimal selection, dose, duration

Reduce or attenuate advancing antimicrobial resistance

Improve patient outcomes and reduce adverse events related to antimicrobials- Decrease Clostridium difficile infection

- Decrease morbidity and mortality

- Decrease length of stay

Decrease healthcare expenditures and antimicrobial costs

Ohl CA. Seminar Infect Control 2001;1:210-21Dellit TH, et al. Clin Infect Dis 2007;44:159-77

Antimicrobial Stewardship Interventions Prospective audit with intervention and

feedback Formulary restriction and preauthorization Educations Streamlining and de-escalating Dose optimization Guidelines and clinical pathways Parenteral to oral conversion

Dellit TH, et al. Clin Infect Dis 2007;44:159-77

Antimicrobial Stewardship Partners

Information Technology

Clinical Pharmacists

Infection Control

Microbiology Lab

Clinicians & Residents

ID Physicians & Fellows

Abx SubcommitteePharmacy and Therapeutics Committee

Administration

SJMAA Antimicrobial Stewardship Program

Focus on restricted abx- New starts, duration

Interventions- Approve- Stop abx- Change/Narrow abx- Obtain ID Consult- Against ASP advice

SJMAA Antimicrobial Stewardship Program

Outcomes from SJMAA ASP (2009-10)

Demographic and clinical characteristics and outcomesof patients pre-ASP compared to patients post-ASP

Multivariable analysis for association of ASP and patient outcomes

Malani AN, et al. Am J Infect Control 2013;41:145-8.

Flow Diagram of Outcomes from ASP

Malani AN, et al. Am J Infect Control 2013;41:145-8.

FY 2009 FY 2010 FY 2011 FY 2012Percent Change

Antimicrobial agents total costs

1,503,748 1,274,837 1,231,079 1,221,275-18.8

(-784,053)

Total patient days 147,955 144,783 146,332 146,310

Antimicrobial costs per patient day (average)

10.16 8.81 8.41 8.35 -17.8

Targeted antimicrobial agents

462,404 297,851 278,998 342,997-25.8

(-467,360)

Antimicrobial Costs by Fiscal Year

Incidence and mortality of CDI are increasing in US

An

nu

al M

orta

lity R

ate

p

er M

illion

Po

pu

latio

n

1. Elixhauser A, et al. Healthcare Cost and Utilization Project: Statistical Brief #50. April 2008. Available at: http://www.hcup-us.ahrq.gov/reports/statbriefs/sb50.pdf.

2. Redelings MD, et al. Emerg Infect Dis. 2007;13:1417-1419.

# o

f C

DI

Ca

se

s p

er

10

0,0

00

Dis

ch

arg

es

National Efforts on Antimicrobial Stewardship

SHEA Task Force IDSA and PIDS CDC Get Smart Campaign – Core Elements

www.cdc.gov/getsmart/ JTC National Patient Safety Goals

(NPSG) 07.03.01 California Senate Bill 739

22% of 135 surveyed CA hospitals influenced to initiate an ASP

Trivedi K, Rosenberg J. Infect Cont Hosp Epi 2013;34:379-84.

Role of the Infection Preventionist

Daily activities of IPs/HEs vital for ASPImplementation of evidenced-based

practice and prevention care bundles (hand hygiene, isolation precautions, environmental cleaning, etc)

No transmission of infection = Avoidance of abx

Role of the Infection Preventionist

Identification and surveillance of MDROs Monitoring and reporting of trends of MDROs Promote high compliance with hand hygiene Track and analyze trends in antimicrobial

resistance Educate multidisciplinary rounding teams about

NHSN surveillance definitions of HAIs Partners for accountability – share findings with

and progress to stakeholders and providers

Moody J, et al Infect Cont Hosp Epi 2012;33:328-30.

Barriers for Antimicrobial Stewardship in Long Term Care

Limited staffing and infrastructure Having clinical providers off-site Decision-making based on communications from

front-line staff Limited diagnostic testing on-site leads to delays

in obtaining, processing, and specimen results

Trivedi K, et al. Infect Dis Clin N Am 2014;28:281-89.

Recommendations for Antimicrobial Stewardship in Long Term Care

Composition of ASP team are different Staff pharmD, IP, Administration – Med. Director,

DON, rep. from nursing/medical staff When available: ID physician (telemedicine)

Development of ASP in settings with limited resources should be approached as “menu of interventions and strategies”

Successful ASPs have been implemented in variety of nonuniversity settings

Trivedi K, et al. Infect Dis Clin N Am 2014;28:281-89.

Strategies for Antimicrobial Stewardship in Long Term Care

Education – complete ASP educational offering Incorporate high-abx prescribing disciplines in

ASP (i.e. hospitalist) Use nonphysician HCP as extenders of ASP Develop, calculate, track basic metrics

Antimicrobial cost/pt day MDRO and CDI trends

Prepare an annual antibiogram Allow pharmacy to make automatic conversions

(IV to PO; dosing: aminoglycoside/vanc,renal)

Trivedi K, et al. Infect Dis Clin N Am 2014;28:281-89.

Strategies for Antimicrobial Stewardship in Long Term Care

Incorporate evidenced-based guidelines into order sets and protocols Loeb criteria proposed to improve abx use McGeer criteria – surveillance definitions in LTCF

Trivedi K, et al. Infect Dis Clin N Am 2014;28:281-89.

How to start Antimicrobial Stewardship in Long Term Care

Identify all interested parties Buy-in from administration

Medical director, DON

Understand current institutional approaches for treating infectious disease syndromes

Identify physician champions Target 2 to 4 abx-related issues

Formulary restriction, etc

Trivedi K, et al. Infect Dis Clin N Am 2014;28:281-89.

Stewardship at Transitions of Care

All pts to get parenteral abx seen by ID prior to d/c at Cleveland Clinic

244 CoPat consultations 175 (72%) approved 66 (28%) avoided 11% consults avoided abx

Targeting pts at transitions of care (hospital to community) is an AS strategy

Shrestha , et al Infect Cont Hosp Epi 2012;33:401-04.

Current State of Stewardship at SJMAA

Track all restricted antimicrobials Track all antimicrobials in high risk pts Use software for surveillance, tracking, clinical

decision support Development of bundles for specific

infections/syndromes Use of antimicrobial timeouts and rapid

diagnostic testing Lead quality initiatives related to abx use (i.e.

SCIP)

Surgical Care Improvement Project (SCIP) Infection-Prevention Measures

1. Stulberg JJ, et al. JAMA 2010;303:2479-2485.

2. File T, et al. Clin Infect Dis. 2011;53:S15-22.

Clostridium difficle Infection Powerplan

Antimicrobial Management Page

Summary

Primary mission of ASPs is patient safety Goals of ASPs are to ensure that there are

systems and support to help providers use antibiotics optimally

ASPs can improve pt outcomes, reduce tx costs, reduce CDI, & reduce or slow the development of resistant organisms

ASPs can and must be implemented across continuum of care

Case # 1

49 y/o F, hx of Downs Recurrent hospitalizations, most recently 1 wk prior Hx of recent clogging of J-tube No fevers WBC 4.5 U/A shows + LE, + nitrites, 10 WBC Urine cx shows MDRO

Case # 1

49 y/o F, hx of Downs Recurrent hospitalizations, most recently 1 wk prior Hx of recent clogging of J-tube No fevers WBC 4.5 U/A shows + LE, + nitrites, 10 WBC Urine cx shows MDRO

* Final Report *URINE CULTURE + SUSCEPTIBILITY Source: URINE Collected: 04/17/11 1219 --------------------------------------------- Culture (Final) COLONY COUNT: >100,000 CFU/ML Escherichia coli THIS ORGANISM PRODUCES AN EXTENDED SPECTRUM BETA- LACTAMASE (ESBL). IT SHOULD BE REGARDED AS RESISTANT TO ALL CEPHALOSPORINS, REGARDLESS OF THE RESULTS OF ROUTINE SUSCEPTIBILITY TESTING.

E.coli ______ MIC 0006054646 ___ __________ AMIKACIN 4 S AMPICILL/SULBAC >=32 R AMPICILLIN >=32 R AZTREONAM >=64 R CEFAZOLIN >=64 R CEFEPIME 16 R CEFTRIAXONE >=64 R CIPROFLOXACIN >=4 R ERTAPENEM <=0.5 S ESBL POSITIVE GENTAMICIN >=16 R MEROPENEM <=0.25 S NITROFURANTOIN <=16 S TOBRAMYCIN >=16 R TRIMETH-SULFA >=320 R

Case # 1

A. Start Ertapenem. B. Start Amikacin.C. Start Meropenem.D. No treatment.

Case # 1Take Home Points

No need to treat asymptomatic bacteriuria

- No urinary tract signs or symptoms- Typical pathogens (not contaminants)- Urine appropriately collected

145 patients with a positive urine culture, defined by having any growth of bacteria or

yeast on a urine culture

70 with asymptomatic

bacteriuria

75 had a UTI based on guideline review

43 treated for a UTI

27 not treated for a UTI

Treatment of Positive Urine Cultures in Hospitalized Patients:A Key Driver of Inappropriate Antimicrobial Use – SJMH AA

145 patients with a positive urine culture, defined by having any growth of bacteria or

yeast on a urine culture

57 with asymptomatic

bacteriuria

88 had a UTI based on guideline review

37 treated for a UTI

20 not treated for a UTI

Treatment of Positive Urine Cultures in Hospitalized Patients:A Key Driver of Inappropriate Antimicrobial Use – Livingston

Case # 2

83 year old male s/p AAA repair Extubated in PACU and tx to the 2000 unit 4 days later, develops respiratory distress, SICU

tx, and reintubation. Further evaluation:

New infiltrate on CXR WBC 26.5Tmax 101.9

Case # 2

Started on Cefepime and Vancomycin. Has PCN allergy (rash).

After 1 wk, WBC decreased to 13.7 Final culture & sensitivities from sputum show: Direct Smear: Moderate neutrophils, GNB

Culture (Final): Enterobacter aerogenes

Enterobacter aerogenes

MIC INTAmpicillin/SulbAmpicillinAztreonamCefazolinCefepimeCeftriaxoneCiprofloxacinGentamicinMeropenemPiper/TazobacTobramycinTrimeth-Sulfa

816<=1>=64<=1<=1<=0.25<=1<=0.25<=4<=1<=20

RRSRSSSSSSSS

Case # 2

Pt received 72 hours of Cefepime/Vancomycin Readdress abx regimen given cx results

A. Continue Cefepime and Vancomycin B. Continue Cefepime. D/C Vancomycin.C. De-escalate Cefepime to a different abx. D/C

Vancomycin.

Case # 2Take Home Points

Antibiotic Timeout (reasons for abx use) Streamlining and de-escalating Duration for abx course Clear plans when transitions of care (tx to/from

ICUs/discharge summaries/ECFs)

Case # 3

Case # 3

88 y/o male, hx of dementia, presented with confusion/weakness

Recent stay at an ECF, presented with foley WBC 13.4 Started on Ceftriaxone Cefepime/Vancomycin Blood cx: ¾ CNS Urine cx: alpha hemolytic streptococcus U/A 57 WBC, + LE

Case # 3

No fevers, exam significant for L knee effusion/pain

ID c/s stopped all abx Underwent arthrocentesis Pseudogout A few days later, started on IV flagyl for CDI Changed over to PO flagyl D/C back to ECF

Case # 3

While at ECF, receives ertapenem for ESBL

E. Coli bacteriuria, and then nitrofurantoin for VRE bacteriuria

Presents 1 month from previous admission with abdominal pain, diarrhea, lethargy, WBC 15.9

Started on IV ceftriaxone/flagyl Seen by ID

Case # 3

A. Add po VancomycinB. D/C Ceftriaxone, add po Vancomycin. C. Change abx to ZosynD. No treatment

Case # 3

Severe CDI Pt eventually goes on hospice despite maximal

medical tx for a wk

Case # 3Take Home Points

Aware of adverse effects of abx including CDI, MDRO, etc

Improved abx use improves pt outcomes AS through continuum of care is critical