Antimicrobial Stewardship & Infection Control: 2 Peas, 1 Pod Jessica Minion, Medical Microbiologist Regina Qu’Appelle Health Region SASKPIC Conference September 2016

Declaration of Conflicts of Interest none

Objectives What is Antimicrobial Stewardship and what does it have to do with me? Why are we talking about this now? What kind of interventions are part of Antimicrobial Stewardship?

Dr. Arjun Srinivasan, Associate Director CDC, Oct 2013: “There have been covers of magazines about the end of antibiotics, question mark; I would say you can change the title to the end of antibiotics, period” Dame Sally Davies, Chief Medical Officer for England: 'Antibiotic resistance is like climate change in that we're doing it to ourselves. But there are no sceptics' Britain has declared antimicrobial resistance to be a threat to the country’s security and economy on par with terrorism and climate change Dr. Tom Freiden, CDC director, 2013 Director World Health Organization, 2012

Timeline of Resistance Development From: McClure NS, Day T. 2014, Proc. R. Soc. B 281: 20141861.

Bacterial Evolution https://www.youtube.com/watch?v=yybsSqcB7mE Cipro and trimethoprim From Atlanta, 1.5 weeks https://www.youtube.com/watch?v=yybsSqcB7mE Video: M. Baym, R. Kishony, R. Groleau, T. Lieberman, R. Chait

Evolution Management 2 complementary strategies available: Increase rate of new drug development Increase time it takes for resistance to develop and spread

Preventing the Antimicrobial Apocalyse Reduce Spread of Resistance Reduce Inappropriate Use of Antimicrobials Reduce Need for Antimicrobials Infection Control Hand Hygiene Public Health Infection Prevention Vaccines

Individual vs. Public Health

Individual vs. Public Health Your mother has a [urinary tract/respiratory/GI/skin] infection Last time she had one, a delay in diagnosis put her in hospital When your doctor selects the antibiotic to treat her, how confident do you want them to be that it will work? 80%? 90%? 95%? 99%? 100%? Goal for community empiric treatment recommendations What I want for my family Someone with a serious resistant bacterial infection (MRSA) is 64% more likely to die from their infection, compared to a person with the same infection from a susceptible bacteria (MSSA). - World Health Organization, May 2015

Individual vs. Public Health Your child is septic (there are bacteria growing in their bloodstream). Untreated sepsis carries a risk of death of 7% per hour When you doctor selects the antibiotic to treat them, how confident do you want them to be that it will work? 80%? 90%? 95%? 99%? 100%? Goal for hospital empiric treatment recommendations What I want for my family “Last Line” antibiotic use has increased 1400% in the last 10 years - Health Canada, April 2015

Doubles every 2 years

Action Plans! EU 2011 $890 million WHO 2015 USA 2015 $1.2 billion UN General Assembly discusses AMR Sept 21 WHO 2015 UK/Wellcome Trust 2016 USA 2015 $1.2 billion Impact by 2050: 10 million lives/yr 100 trillion USD

Canadian AMR Action Plan 3 Pillars Surveillance (CARSS) Stewardship Human Animal Research & Innovation Oct 2014 Mar 2015

It Starts With Awareness “Right drug, Right dose, Right route, for the Right duration, for the Right indication” Educational Messages: Viral vs. Bacterial illness Effects on Microbiome C. difficile Drug side effects and adverse events Cost Primary driver of resistance

Point of Prescription Toolkit Physician Compact

Point of Prescription Toolkit Physician Compact Viral Prescription Pads

Point of Prescription Toolkit Physician Compact Viral Prescription Pads Patient Education

Point of Prescription Toolkit Physician Compact Viral Prescription Pads Patient Education Academic Detailing

Accreditation Requirement Improve patient outcomes Reduce antibiotic resistance Save Money Introduced 2012; Evaluations began 2013 USA – all hospitals by 2020

Hospital Antimicrobial Stewardship Programs Organization of Program Prospective Audit & Feedback Formulary Restriction & Preauthorization Other CID 2007, Vol 44 (Jan 15):159 CID 2016, Vol 62 (May 15):e51

Antimicrobial Stewardship Core Team Organization Antimicrobial Stewardship Core Team Infectious Disease (ID) Physician* Clinical Microbiologist Information System Specialist ID Clinical Pharmacist* Hospital Epidemiologist Infection Control Professional *A-II recommendations, others are A-III

Prospective Audit & Feedback Time intensive, direct interaction between ASP team members and prescribers Step 1 – Pick High Priority Audit Topic Step 2 – Engage Relevant Prescribers Step 3 – Audit in Real Time Step 4 – Provide Feedback in Real Time Step 5 – Measure Uptake

Prospective Audit & Feedback Example: Step 1: PipTazo use in the ER Step 2: Discuss and find agreement with ER physicians about when PipTazo should be used Step 3: When ER orders PipTazo, ASP Team reviews patient and determines if order is appropriate Step 4: Discuss with ordering physician Step 5: Record results of audit/feedback process

Formulary Restriction & Pre-Authorization Already in place at most hospitals in some form or another Review Antibiotics available Do not carry; special access application required Available, but only *after* pre-approval Available, but only for a limited duration Available, but only for specific indications Routinely available

Prospective Audit & Feedback Example: Restricted – Ceftolozan/Tazobactam is a new antibiotic that the hospital decides to not include it on their formulary, but if clinical situation arises that it’s needed physician can fill out form and request to bring it in Example Pre-Approval – Daptomycin is available in the hospital, but only Infectious Disease and ICU physicians are allowed to prescribe it Limited Duration – Piptazo is available for any physician to order, but it will be automatically stopped after 72 hours unless reordered by Infectious Disease physician Limited Indication – Linezolid is available only for culture-confirmed infection with vancomycin-resistant organism

Other Potential Initiatives Syndrome Specific Guidelines and Clinical Pathways** Rapid Diagnostics** Antimicrobial Cycling Antimicrobial Order Forms/Indications Streamlining or De-escalation of Therapy IV to PO conversion Microbiology ordering/reporting Clinically-oriented antibiotic cascades Combination Therapy, Dose Optimization, PK/PD therapeutic drug monitoring Allergy Reconciliation Clinical Decision Support Systems ** strongly recommended in 2016 guideline update

Outcome Measures Antimicrobial Usage (DDD, DOT) Cost Avoidance/Savings (drug costs, hospitalizations, AEs) Resistance patterns (antibiogram) HAIs (C.diff, MDROs) Clinical Endpoints (mortality, length of stay)

IPAC & ASP Common Strategic Goal Educational Messages – synergy! Surveillance Joint Initiatives Outbreak Interventions Support & Mentorship

Summary Primary goal of ASP & IPAC is the same – to control the development & spread of antimicrobial resistance Emphasis on AMR increasing; expect to see greater top-down emphasis and attention Primary players for ASP are physicians & pharmacy (& patients) Formulary Interventions & Prospective Audit/Feedback are core ASP activities IPAC should be part of core ASP Team Opportunities to collaborate and share resources, expertise, data, education…

Bacterial Evolution https://www.youtube.com/watch?v=yybsSqcB7mE