-
5/7/2012
1
Intermountain APIC and Qualis Health
present
I-APIC HAI Prevention Learning Network Webinar Series
Antimicrobial Stewardship in Infection Prevention
May 9, 2012
Julia Moody MS, SM(ASCP)Director, Infection Prevention
Clinical Services Group
HCA, Inc., Nashville, TN
Slide: 2
Objectives• Discuss the urgent need and value for antimicrobial
stewardship
programs
• Review the current state of antimicrobial resistance patterns
and issues related to resistance.
• Recognize impact of resistance on population/patient
health
• Discuss global-to-local program strategies for decreasing
antibiotic resistance
• Clarify day-to-day infection preventionist duties related to
antimicrobial stewardship
• Describe how to participate or lead planning and
implementation of appropriate antimicrobial stewardship strategies
in various healthcare settings
-
5/7/2012
2
Slide: 3
Case Study: “How Hardwired are your Infection Prevention
Practices?”
• 35yo ventilator dependent quadrapalegic is a frequent
readmission; and this stay is from LTACH (long term acute care
hospital) to acute care hospital MICU with pneumonia due to
Pseudomonas aeruginosa resistant to all antibiotics except for
amikacin
• Pharmacy indicates Amikacin is not available due to a nation
wide drug shortage; colistin susceptibility pending
• Bed supervisor calls infection prevention for guidance
• Preventing transmission of this resistant MDRO is reliant on
highly compliant infection prevention practices
Slide: 4
Colonized and infected patients are links in the chain of MDRO
transmission between
neighboring healthcare settings
Ambulatory Care settings
Acute carehospitals Skilled nursing
facilities
Colonized or recently Infected patients
Older individualsIn community
Acute carehospitals
Skilled nursing facilities
-
5/7/2012
3
Slide: 5
Magnitude of Antimicrobial Use
• Antibiotics are the second most commonly used class of drugs
in the United States
• More than 8.5 billion dollars are spent on anti
-infectivesannually
� 200-300 million antimicrobials prescribed annually
� 53% for outpatient use
• 30-50% of all hospitalized patients receive antibiotics
• Studies estimate up to 50% of antibiotic use is either
unnecessary or inappropriate across all type of health care
settings
Clin Infect Dis 2007; 44:159-177
Slide: 6
192 187
94
0
50
100
150
200
250
Duration of Therapy
Longer than Necessary
Noninfectious or
Nonbacterial Syndrome
Treatment of
Colonization or
Contamination
Da
ys
of
Th
era
py
Unnecessary Use of Antimicrobials in Hospitalized Patients
• Prospective observational study in ICU
• 576 (30%) of 1941 antimicrobial days of therapy deemed
unnecessary
Hecker MT et al. Arch Intern Med.
2003;163:972-978.
Most Common Reasons for Unnecessary Days of Therapy
-
5/7/2012
4
Slide: 7
Why Improve Antimicrobial Use?
• Antimicrobial agents are misused in hospitals
• Antibmicrobial misuse adversely impacts patients and
society
• Antimicrobials are the only drug where use in one patient can
impact the effectiveness in another.
• Improving antimicrobial use improves patient outcomes and
saves money
• Improving antimicrobial use is a public health imperative
Slide: 8
0
2
4
6
8
10
12
14
16
'83-'87 '88-'92 '93-'97 '98-'02 '03-'07 '08-'12
To
tal
# N
ew
An
tib
acte
ria
l A
gen
ts
Antibiotic Development
-
5/7/2012
5
Slide: 9
Antimicrobial Agents Opportunities • Reduce overuse and
misuse
– Given when not needed
– Drug/bug mismatch and is the wrong antibiotic for
treatment
– Given at the wrong dose-renal and weight-based dosing
– Broad spectrum agents are used to treat very susceptible
bacteria-de-escalation
• Impact of overuse and misuse on healthcare
– Increases mortality and morbidity
– Antimicrobial resistance is accelerated by excessive use of
antibiotics
– Antibiotic-resistant infections have been estimated to cost
the US healthcare system over $20 billion annually
Slide: 10
Hospital and Societal Costs of Antimicrobial-ResistantInfections
in a Chicago Teaching Hospital:
Implications for Antibiotic StewardshipCLIN INFECT DIS
49(8):1175-1184.
-
5/7/2012
6
Slide: 11
Case Study
• 56 year old white female admitted with hypotension, fever, and
flank pain. Her urine showed pyuria and bacteriuria, the peripheral
WBC was 16,000. She was admitted to the ICU and empirically started
on cefepime.
• On day 2, urine and blood grew E. coli sensitive to all tested
antibiotics except ampicillin. Patient stabilized and was
transferred to a nonICUmedical ward. Cefepime was continued.
• On day 5, the patient spiked a new fever. Blood cultures were
drawn and grew _______. Antibiotics were changed to _______.
• On day 7, the patient’s WBC increased to 30,000, new onset
abdominal pain and developed multiple episodes of unformed stools.
Diagnosis: _______
Slide: 12
Multidrug-Resistant Organisms (MDROs) Definitions
-
5/7/2012
7
Slide: 13
MDROs of Epidemiologic SignificanceMDRO
AcronymMicroorganism(s) Antimicrobial Resistance
MRSA Methicillin Resistant Staphylococcus aureus
Oxacillin MIC >4 ug/ml or mecApositive
VISAVRSA
Vancomycin Intermediate S. aureusVancomycin Resistant S.
aureus
(I) Vancomycin MIC 4-8 ug/ml(R) Vancomycin MIC >16 ug/ml
VRE Vancomycin Resistant Enterococci Vancomycin MIC >32
ug/ml
CRE Carbapenemase producing Enterobacteriaceae gram negative
bacilli
Imipenem or MeropenemMIC >4 ug/ml (CLSI 2011);Positive
Modified Hodge test
ESBL Extended spectrum beta-lactamaseenzyme producers (ie. E.
coli, K. pneumoniae)
Resistance to 3rd generation cephalosporins (CLSI 2011); ESBL
MIC confirmation
Pseudomonas aeruginosa Imipenem or MeropenemMIC >16 ug/ml
Acinetobacter baumanii Imipenem or MeropenemMIC >16 ug/ml
Slide: 14
MDROs Associated with Healthcare-Associated Infections as
Reported to
NHSN
-
5/7/2012
8
Slide: 15
Device-Associated and Surgical Site HAIs Due to MDROs as
Reported to CDC/NHSN
Hidron et al. ICHE 2008 (29):996-1011
Total =16% All HAIs associated with MDROs
8% MRSA
4% Vancomycin-resistant Enterococcus faecium
2% Carbapenem-resistant Pseudomonas aeruginosa
1% ESBL cephalosporin resistant Klebsiella pneumoniae
0.5% ESBL cephalosporin resistant Escherichia coli
0.5% Carbapenem resistant Acinetobacter baumannii, K.
pneumoniae, K. oxytoca, E. coli
Slide: 16
Device-Associated and Surgical Site HAIs Due to MDROs as
Reported to CDC/NHSN
Hidron et al. ICHE 2008 (29):996-1011
Microorganism Device* AssociatedHAIs Resistance
Surgical HAIs Resistance
Staphylococcus aureus 56% MRSA 49% MRSA
Enterococcus species 33% VRE 19.7% VRE
Pseudomonas aeruginosa 31% Fluoroquinolone25% Carbapenems
15.9% Fluoroquinolone11.8% Carbapenems
Escherichia coli 5.5% to 11% ESBL0.9% to 4% Carbapenems
5.3% ESBL2.5% Carbapenems
Klebsiella pneumoniae 21% to 27%ESBL3.6% to10.8% Carbapenems
15.8% ESBL5.2% Carbapenems
Acinetobacter baumaniii 25.6% to 36.8% Carbapenems
30.6% Carbapenems
*Devices include central line catheters, urinary catheters and
ventilator associated pneumonia
-
5/7/2012
9
Slide: 17
Antimicrobial Resistance for Selected Pathogens over Time
ICHE.2008;29;1012.
Slide: 18
http://www.cdc.gov/getsmart/healthcare/index.html
-
5/7/2012
10
Slide: 19
http://hcupnet.ahrq.gov
Slide: 20
Two Types of Resistance• Natural (Intrinsic)
– Inherent attribute
– E. coli, a gram negative bacilli and Vancomycin, an antibiotic
with activity against gram positive bacteria
– Translation: gender or race traits are inherent
• Acquired
– Noninherent attribute usually acquired in genetics, by
mutation/evolution or received elements
– An antimicrobial agent once effective is no longer
– Example: Staph aureus resistance to Levofloxacin
-
5/7/2012
11
Slide: 21
Three Mechanisms of Genetic Adaptation
• Transformation: direct incorporation of free DNA
• Transduction: DNA transfer by a replicating virus
– Bacteriophage
• Conjugation: transfer of genes to a neighboring bacterium in a
small circular DNA molecule
– Plasmid
• Bacteria are prolific and some replicate fast
– E. coli doubles every 20 minutes
Slide: 22
Five Mechanisms of Acquired Resistance
• Drug Inactivation – enyzme production like beta-lactamases,
carbapenemases
• Cell Wall Changes - impermeable
• Altered Targets – mutational change no longer binding the
agent
• Efflux Pumps – expels the antibiotic before reaching the
target
• Bypass Targets- mutational change in DNA changing the
metabolic energy pathway
-
5/7/2012
12
Slide: 23
Drug Inactivation
• Beta-lactamases like ESBL
– Engender resistance to penicillin and cephalosporin classes of
antibiotics
– Examples: Klebsiella pneumoniae, E. coli
• Carbapenemases
– Engender resistance to imipenem or meropenem
– Examples: Klebsiella pneumoniae, Pseudomonas aeruginosa
• Enzyme break antibiotics down into ineffective molecules
before reaching the target
Slide: 24
Drug Inactivation
Enzyme is the bolt cutter => Broken Molecule
-
5/7/2012
13
Slide: 25
Cell Wall Changes
• Target in cell wall changes and no longer binds the agent
• Examples:
– MRSA and PBP2a and Methicillin/Oxacillin
Slide: 26
Cell Wall Changes
• Barrier to the antibiotic binding or getting into the cell
• Example: Fortress prevents access to the target
-
5/7/2012
14
Slide: 27
Altered Target
Mutation that no longer binds the antimicrobial agent
Translation: Key no longer works in the door lock
Example: Gentamicinor erythromicinresistance
Slide: 28
Efflux Pump
• Pump in swimming pool or the boat ejects water out when level
gets too high
• Example: Fluoroquinolone(levoquin or ciprofloxacin) resistance
in E. coli
-
5/7/2012
15
Slide: 29
Bypass target
• Changed metabolic energy generating pathway
• Example: E. coli & Trimethoprim/Sulfa
• Translation: Change to another path way like a maze
Slide: 30
Antibiotic Misuse Adversely Impacts Patients: Clostridium
difficile
• Antibiotic overuse contributes to the growing incidence of C.
difficileinfection in healthcare facilities.
• Antibiotic exposure is the single most important risk factor
for the development of Clostridium difficile infection (CDI).
– Up to 85% of patients with CDI have antibiotic exposure in the
28 days before infection
• Emergence of the NAP-1/BI or “epidemic” strain of C. difficile
has intensified the risks associated with antibiotic exposure.
• Epidemic strain of C difficile is associated with increased
risk of morbidity and mortality.
• Epidemic strain is resistant to fluoroquinolone antibiotics,
which confers a selective advantage
Chang HT et al. Infect Control Hosp Epidemiol 2007;
28:926–931McDonald LC et al. N Engl J of Med 2005;353:2433-41
-
5/7/2012
16
Slide: 31
Cumulative Antibiotic Exposures Over Time and the Risk of
Clostridium difficile Infection(CDI)
Clin Infect Dis 2011;53:42
• Observed dose dependent increases in the risk of CDI
associated with increasing cumulative dose, number of antibiotics,
and days of antibiotic exposure.
• Compared to patients who received only 1 antibiotic, the
adjusted hazard ratios (HRs) for those who received 2, 3 or 4, or 5
or more antibiotics were 2.5, 3.3, and 9.6,
respectively(overlapping).
• The receipt of fluoroquinolones was associated with an
increased risk of CDI, while metronidazole was
associated with reduced risk.
Slide: 32MMWR 2011; 60:1171
-
5/7/2012
17
Slide: 33
Impact of Effective Antibiotic Stewardship Programs on C.
difficile Infections
• NAP1/027 strain of C. difficile decreased 60% with total and
targeted antibiotic consumption decreased 23% and 54%.
– Valiquette et al. CID 2007 45 (Suppl 2) S112-S121
• C. difficile decreased 41% from 7.2 to 4.8 per 1000 discharges
with decreased clindamycin and fluoroquinolone usage
– Muto et al. CID 2007, 45:1266-1273
• C. difficile decreased from 2.2 to 1.4 cases per 1000
discharges with 22% decrease in parenteral broad-spectrum
antibiotics
– Carling et al. ICHE 2003:24(9): 699-706
• Other MDRO resistance rates change slowly and can be
influenced by other factors in addition to antibiotic use.
http://www.cdc.gov/getsmart/healthcare/support-efforts/asp-int-cdiff.html
Slide: 34
Role of Infection Prevention Science in Antimicrobial
Stewardship
• Accelerate progress towards preventing emergence
andtransmission of MDROs by applying skills and knowledge
ofinfection preventionists and healthcare epidemiologists
• Identify and report trends and outbreaks of
epidemiologicallysignificant organisms; educate for understanding
about infectionprevention interventions
• Provide support and guidance in approaches to surveillance
forsyndromes of interest
• Implement interventions to guide delivery of
evidence-basedpractices
• Translate data and infection rates to HCW and leadership
-
5/7/2012
18
Slide: 35
Antimicrobial Stewardship: Role of the Infection
Preventionist
• Implement care bundles and checklists to reduce the riskof
getting an infection from use of catheters and devicesor after
undergoing a surgical procedure
– Surgical Site infection (SSI)
– Central Line-Associated Bloodstream Infection (CLABSI)
– Catheter Associated Urinary Tract Infection (CAUTI)
– Ventilator-Associated Pneumonia (VAP)
– Clostridium difficile
– Methicillin Resistant Staphylococcus aureus (MRSA)
– Vancomycin-Resistant Enterococcus (VRE)
– Multidrug-resistant Acinetobacter baumannii
Slide: 36
Antimicrobial Stewardship:Infection Preventionist Knowledge and
Skill Set
• Proficient in evaluating microbiology culture and
susceptibility results.Differentiates between colonization,
contamination and pathogens
• Recognizes epidemiologically significant MDROs and
atypicalsusceptibility patterns in microbiology results
• Performs surveillance and trending of MDROs for prevalence
andnewly emerging MDROs
• Knowledgeable of effective hand hygiene, isolation practices
andproducts and procedures for environmental cleaning and
disinfectionand evidence based infection prevention practice
bundles
• Develops and exhibits leadership promote shared accountability
forhighest compliance with practice and multidisciplinary rounding
forimproved patient outcomes
-
5/7/2012
19
Slide: 37
Antimicrobial Stewardship: Role of the Infection
Preventionist
• Collaborate with microbiology, pharmacy, medical staff,and
administration to plan and implement effectiveinterventions to
prevent MDRO in healthcare facilities
• Perform an annual infection prevention risk assessmentfor
MDROs
• Meet regulatory requirements of The Joint CommissionNPSG
07.03.01
• Proposed new CMS Conditions of Participation forInfection
Prevention assess systems to preventtransmission of MDROs and
stewardship activities
Slide: 38
Antimicrobial Stewardship:Microbiology Collaborative
• Specimen Collection Quality• Assure optimal specimens for
valid results and optimal antibiotic selection.
• Focus on high frequency specimens known to have volume,
adequacy andmicrobial flora contamination challenges
• Specimen preservation and timely collect to plating to
preserve the microbial pictureat time of collection
• Gram stain, such as quantified WBC, epithelial cells and
bacteria to evaluate quality
• Identification and susceptibility testing for clinically
significantpathogens• Correlation of gram stain to culture
results
• Quantitation of microbial growth in cfu/ml, few/moderate/many,
or 1+, 2+, 3+, 4+
• Identification to genus and species or susceptibility testing
is limited on specimensfrom nonsterile sites
• Use of CLSI standards for susceptibility testing and
preparation ofcumulative antibiograms
-
5/7/2012
20
Slide: 39
Antimicrobial Stewardship:Epidemiologic Aspects
• Retain clinically significant pathogens with novel or atypical
resistance patterns
• Report to local state Department of Health when indicated
– One time event may qualify as an outbreak (ie first event of
CRE)
– Determine occurrences in the region
• Send pathogen for epidemiologic study of resistance to a DOH
or recognized research laboratory
Slide: 40
Apply Infection Prevention Knowledge: Community Based Hospital
Experiences
• Community based facilities deliver the majority of inpatient
care in the US
– Bed size range from
-
5/7/2012
21
Slide: 41
Examples ofInfection Preventionist Collaboration
• Review all positive blood cultures
– Coagulase negative staphylococci (CoNS) and other
skincontaminants are common
– Implement strategies to reduce skin contaminants
• Identify negative cultures and antibiotics beingadministered
to review for appropriateness/necessity
• Advocate for appropriate specimen collection, diagnosisand
treatment of symptomatic UTI’s
• Endorse computer physician orders; evidence basedorder sets
for syndromic diseases/conditions
Slide: 42
Antimicrobial Stewardship: Case Study• 56 year old white female
admitted with hypotension, fever, and flank
pain. Her urine showed pyuria and bacteriuria, the peripheral
WBC was 16,000. She was admitted to the ICU and empirically started
on cefepime.
• On day 2, admission urine and blood grew E. coli sensitive to
all tested antibiotics except ampicillin. Patient stabilized and
was transferred to a nonICU medical ward. Cefepime was continued.
Missed opportunity to de-escalate antimicrobial treatment
• On day 5, the patient spiked a new fever. Blood cultures were
drawn and grew Enterococcus faecalis. Antibiotics were changed to
Ampicillin/Sulbactam.
• On day 7, the patient’s WBC increased to 30,000, new onset
abdominal pain and developed multiple episodes of unformed stools.
Diagnosis: Clostridium difficile
-
5/7/2012
22
Slide: 43
Antimicrobial Stewardship:Infection Prevention Take-Aways
• Evaluate your infection prevention knowledgeand skills. Obtain
education and experience tofill gaps.
• Evaluate your annual infection prevention planand incorporate
antimicrobial stewardshipactivities and MDRO reporting
• Increase your visibility and leadership ininfection prevention
and antimicrobialstewardship
Slide: 44
Resources
• CDC
– http://www.cdc.gov/drugresistance/index.html
– http://www.cdc.gov/getsmart/index.html
– http://wwwn.cdc.gov/dls/master/ams/intro/open.swf
• WHO
– http://www.who.int/mediacentre/factsheets/fs194/en/
• Antimicrobial Stewardship: A collaborative partnership between
infection preventionists and health care epidemiologists. AJIC (20)
2012 94-95
-
5/7/2012
23
Slide: 45
Questions?
[email protected]
46
Save-the-Date: I-APIC HAI Series
Hand Hygiene: Engaging Patients and FamiliesWednesday, June 13,
1pm MT/12pm PTTimothy Landers, CNP, PhD
Summer Bugs: Summer Season Epi TrendsWednesday, July 11, 1pm
MT/12pm PT
Central Line InfectionsWednesday, August 8, 1pm MT/12pm PT
-
5/7/2012
24
47
Contact Information
Quality Improvement Organizations
Jennifer PalagiQualis Health, Idaho QIO
[email protected]
Tina SchwienQualis Health, Washington QIO
[email protected]
Laurie Murray-SnyderAcumentra Health, Oregon
[email protected]
503.382.3927
Julia [email protected]
Intermountain APIChttp://apicintermountain.com/Trish Heath,
Education Lead
[email protected] Maggard, President
[email protected]
This material was prepared by Qualis Health, the Medicare
Quality Improvement Organization for Idaho and Washington, under
contract with the Centers for Medicare & Medicaid Services
(CMS), an agency of the U.S. Department of Health and Human
Services. The contents presented do not necessarily reflect CMS
policy. ID/WA-C7-QH-799-05-12
48
Presentation Evaluation
• Will automatically pop-up when you close out of presentation
on your computer
• Share the evaluation link below with others attending with
you, to capture their feedback
Brief Survey Monkey:
https://www.surveymonkey.com/s/3VZ3ZJY