There Aren't Any New Ones - Why Antibiotic Stewardship is now Essential

The New World of Stewardship Jim Hutchinson

Medical Director - Antimicrobial Stewardship Island Health

Clinical Lead – Antimicrobial Stewardship BCPSQC

Muir Glacier Alaska

1940 2004

Penicillin Resistant S. aureus

Chambers et al EID 2001

Resistance to antibiotics rapidly rising

No new antibiotics

Infections are not diagnosed well

Antibiotics are not prescribed well

The Solution?

Structure

Thought

Care

Collaboration

Data

Required Organizational Practice: The organization has a program for

antimicrobial stewardship to optimize antimicrobial use.

Spurred BC Action

BC Ministry of Health

• New Clinical Care Management area • Established Provincial Antimicrobial

Clinical Expert group

PACE

PACE

• Co-Chaired by Richard Bachand and I with ministry support

• Established in spring 2013 • Aggressive work plan

PACE activities

• Best practice review completed • Survey of stewardship capacity completed • Business case RFP out • Assuming responsibility for the Antibiotic /

Probiotic portions of the Provincial Hospital Formulary

PACE activities

• Best practice review completed • Survey of stewardship capacity completed • Business case RFP out • Assuming responsibility for the Antibiotic /

Probiotic portions of the Provincial Hospital Formulary

Which targeted antimicrobial stewardship activities are done at this facility?

0% 10% 20% 30% 40% 50% 60% 70% 80%

Other

Prospective Audit with Intervention and Feedback

Pre-Authorization

Guidelines and Clinical Pathways

Education Program

Formalized IV to PO Conversion Program

Time-sensitive Automatic Stop Orders

26

Which targeted antimicrobial stewardship activities are done at this facility?

0% 10% 20% 30% 40% 50% 60% 70% 80%

Other

Prospective Audit with Intervention and Feedback

Pre-Authorization

Guidelines and Clinical Pathways

Education Program

Formalized IV to PO Conversion Program

Time-sensitive Automatic Stop Orders

27

Prospective Audit with Intervention and Feedback By Health Authority

0

1

2

3

4

5

FHA IHA NHA PHC PHSA VHCA VIHA

Num

ber o

f Fac

ilitie

s

Audit and Feedback

Unsolicited Help

Helping everyone use antibiotics well

Clinical Pharmacy backbone

• Clinical Pharmacists are the “Foot Soldiers”

• We don’t have enough • We MUST build capacity

Clinical Pharmacy backbone

This is essential

Centralized medical oversight

• Infection specialists (ID and Medical microbiologists) provide direct and responsible collaborative help to clinical pharmacists.

• This is not the usual model of physician interaction and oversight

Multidisciplinary help the process • Clinical pharmacists find people with

infections – By antibiotic prescription – By microbiologic Dx – By algorithm

• Advise on their management in collaboration with Specialist physician

• Follow-up

Multidisciplinary help the process

It’s not Rocket Science

Multidisciplinary help the process

But it is tricky!

Multidisciplinary help the process

• Trust must be established • Collegial, educational, non-punitive • Direct physician to physician interaction

very important at the outset

Progress in Island Health

• Friends are being made • Foundations are being built

Unsolicited Help Clinical pharmacists hired in:

• Nanaimo • Campbell River • Cowichan District • Victoria

Unsolicited Help

• They have found hundreds of patients • They have phoned me (and my

colleagues) many, many times • They have helped!

And most importantly…

Now they are local, trusted, collaborative colleagues

PACE activities

• Best practice review completed • Survey of stewardship capacity completed • Business case RFP out • Assuming responsibility for the Antibiotic /

Probiotic portions of the Provincial Hospital Formulary

Which of the following metrics are used to evaluate antimicrobial usage?

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

Defined Daily Dose Days of Therapy Length of Therapy Total Cost ofAntibiotics

None Other

45

Not much measuring

But every prescription is electronic…

Hmmm…

SEISMIC

SEISMIC Surveillance and Epidemiology of Infections, Stewardship, Microbiology, and Infection Control

A Quality Assurance & Surveillance Analytical

Environment for Microbiology, Antibiotic Stewardship and Infection Control

“a roadmap for the development of enhanced clinical

analytical capacity within Island Health”

“a roadmap for the development of enhanced clinical analytical capacity within

Island Health”

SEISMIC

• Extension of the Business Intelligence Data Warehouse

• Re-purposing transactional data to facilitate quality care

What data is needed for quality management of infections? • Antibiotic use • Antibiotic resistance

– “Antibiogram” • Measures of inflammation

– e.g. WBC, Temperature, Procalcitonin • Outcome measures

– e.g. LOS, mortality, complications, readmissions

First blush

• Antibiotic use • Based on orders

– Much better to use administration data

Future of SEISMIC

• Relate antibiotic use to resistance • Relate antibiotic use to outcomes • Predict appropriate empiric therapy by

personal microbiologic history • Etc., etc., etc.

Future of SEISMIC

Iterative analysis

Forever

The ultimate vision

• All people on Vancouver Island will have their infections anticipated, prevented, diagnosed and treated in a thoughtful, efficient, SYSTEMATIC fashion.

The ultimate vision

• All people in British Columbia will have their infections anticipated, prevented, diagnosed and treated in a thoughtful, efficient, SYSTEMATIC fashion.

We are building a permanent system

Why just antibiotics?

Stewardship of everything