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How to Start an Antimicrobial Stewardship Program


How to Start an Antimicrobial Stewardship Program In Conjunction with AzHHA s Safe and Sound Patient Safety Initiative Patty Gray RN, CIC & Bill Wightkin, Pharm D, R.Ph – PowerPoint PPT presentation

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Title: How to Start an Antimicrobial Stewardship Program

How to Start an Antimicrobial Stewardship Program
  • In Conjunction with AzHHAs Safe and Sound
    Patient Safety Initiative
  • Patty Gray RN, CIC Bill Wightkin, Pharm D, R.Ph

Learning Objectives
  • After listening to the presentation, viewing
    Power Point slides and participating in a
    question and answer session, the participant
  • A. Be able to list the recommended
    components of an antibiotic
  • stewardship program
  • B. Be able to detect antibiotic use
    improvement opportunities
  • from the analysis of utilization data
  • C. Be able to explain the barriers for
  • implementation of such a program

Presentation Outline
  • I. Why Develop an Antimicrobial Stewardship
  • A. Infection control nurses perspective
  • B. Hospital pharmacists perspective
  • II. Recommended Components of a Program
  • III. Scottsdale Healthcares Program
  • A. Short history
  • B. Committee membership and
  • C. Goals of the committee
  • D. Activities-to-date
  • E. Results so far
  • F. Opportunities for improvement
  • G. Next steps
  • IV. Audience questions and answers

Why Develop an Antimicrobial Stewardship Program
  • From an Infection Preventionist Perspective
  • Track and Reduce antimicrobial resistance
  • Encourage appropriate treatment patterns The
    right antibiotic, for the right duration
  • Develop a collaborative practice between
    MDs/LIPs, Pharmacy, Laboratorians and Infection
    Preventionists with best patient outcome in mind
  • Education Catalyst

Why Develop an Antimicrobial Stewardship Program?
  • Hospital Pharmacists Perspective
  • Allows needed FOCUS on a drug class
  • Need to assure appropriate medication management
    and safety
  • Assist with educational efforts
  • Assist with formulary standardization
  • Control costs

Antimicrobial Purchases
Yearly Expense
Daptomycin 696,000
Pip/Tazo 585,000
Zyvox 444,000
Primaxin 415,000
Caspofungin 400,000
Levofloxacin 338,000
Invanz 335,000
Tygacil 284,000
Expense of Top 100 Drugs 17.5 million/yr
Antimicrobials 5 million/yr 29
Recommended Components of an Antimicrobial
Stewardship Program
  • Foundation 2 core, proactive strategies
  • Prospective audit with intervention and feedback
  • Formulary restriction and preauthorization

Other Recommended Components of an Antimicrobial
Stewardship Program
  • Standardized order sets and clinical pathways
  • (foster evidence-based prescribing)
  • Antimicrobial order forms
  • De-escalation of therapy (Review CS results
    on-going review of therapy)
  • Dose optimization (right dose for site of
  • renal dose adjustment)
  • IV to oral dose conversion

Scottsdale Healthcares Program History
  • Evolution from an Antibiotic Subcommittee of the
    PT Committee
  • Perception of an Antibiotic Restriction and
    Control Approach
  • Acknowledgement of Hospital and Community
  • Need for Administrative and Board Support
  • Mission Development Educational/Cooperative
    Focus Stewardship
  • University of Kentucky Program- Dr. R. Rapp
  • New Hospital with need for guidelines upon
    opening of facility

SHC Program Committee Membership and Leadership
  • Medical Staff- Active participation is critical
    to success
  • Includes Chief Medical Officer support, ID ,
    Hospitalists, Intensivists, Pulmonary, ED,
    Community MDs and others as willing
  • Pharmacy- Coordinates the efforts of the team,
    guideline development, education and tracking
  • Infection Prevention Control- Prevention
    Strategies, hand hygiene, precautions, medical
    staff-nursing laison
  • Microbiology- Data trends, special testing
  • Quality Organizational Development- Performance
    Improvement guidance meeting guidance

Goals of Committee
  • Assist providers in appropriate use of
    antimicrobial therapy with improved patient
  • Slow the development of antimicrobial resistance
  • Develop evidence- based appropriate use
  • Educate providers and staff regarding guidelines
  • Track resistance patterns and report back to
    medical and hospital staff
  • Report committee progress and outcomes to PT,
    and Executive Committees

Activities to Date
  • Developed guidelines for 4 antimicrobials
  • Day 7 of therapy reminder to chart
  • Day 10 of therapy phone call from pharmacy ID
  • Drug utilization evaluation (DUE)

(No Transcript)
Results so far (2 months of data)
Drug of patients with an Infectious Disease Physician Consultation Criteria Non-Conformance Rate
Caspofungin 100 (30 patients) 23 (no de-escalation to another agent with Candida albicans)
Daptomycin 93 (41 patients) 24 (no trial of vancomycin for skin infections)
Linezolid 82 (33 patients) 64
Tigecycline 79 (34 patients) 68
Opportunities for Improvement
  • DUE reveals significant non-conformance to
    adopted guidelines
  • Are guidelines appropriate?
  • It does not appear that ID physicians are
  • engaged in the stewardship activities
  • Stewardship Foundation 2 core, proactive
  • Is our process ROBUST (interventions after
    7-10 days)??

Barriers Opportunities for Improvement
  • Cultural Perceptions- Medicines Heirarchy
  • Integration of Team Approach and Evidenced Based
    Practice into culture
  • Continued Involvement of Hospitalists Community
  • Infectious Disease MDs support, agreement use
    of guidelines
  • Turnover of Pharmacy Leadership
  • Ongoing Administrative Support

Next Steps
  • Re-evaluate physician leadership
  • Formulary evaluation caspofungin vs. micafungin
    vs. anidulafungin
  • Transition from faculty ID pharmacist leadership
  • SHC pharmacy clinical staff
  • 4. Explore expansion of pharmacist clinical
    duties to include
  • antimicrobial stewardship responsibilities
  • 5. Improvement of the 2 core proactive strategies

Next Steps
  • ASK WHY...determine and address prime causative
    factors that have resulted in
  • Antibiotic overuse
  • Sub-optimal antibiotic selection
  • Too long duration of therapy
  • Lack of de-escalation to more appropriate agents
  • Slow switch to oral therapy
  • Marketing pressure?
  • Education-Training-Competency?
  • Workload issues with poor attention to detail?
  • Insufficient pharmacy involvement?

  • Dellit TH, Owens RC, McGowan JE, et al.
    Infectious Diseases Society of America
  • and the Society for Healthcare Epidemiology
    of America guidelines for
  • developing an institutional program to
    enhance antimicrobial stewardship.
  • Clin Infect Dis. 44 (1) 159-177, 2007.
  • McQuillen DP, Petrak RM, Wasserman RB, et
    al. The value of infectious disease specialists
    Non-patient care activities. Clin Infect Dis.
    471051-1063, 2008.
  • Spellberg B, Guidos R, Gilbert D, et al.
    The epidemic of antibiotic-resistant
  • infections A call to action for the
    medical community from the Infectious
  • Diseases Society of America. Clin Infect
    Dis. 46 (2) 155-164, 2008.

Antimicrobial Stewardship
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