Antimicrobial Stewardship at Swan District Hospital -A Memoir

Swan District Hospital 200 bed Secondary General Hospital Obstetrics, Paediatrics Emergency Dept General Medicine 60 beds, 6 high acuity General Surgery Acute Geriatrics, Stroke, Rehabilitation Mental Health, Elderly Mental Health

W.A. AMS ‘Timeline’ Mid-1990’s SCGH: Multi-resistant Acinetobacter baumanii in ICU. Widespread restriction 3rd generation cephalosporins 2001: VRE outbreak RPH - $2.4 million to contain. Stimulates RPH AMS Program. 2010: 0.5 FTE ID physician and 0.2 FTE pharmacy approved for SDH AMS. 2012: AMS part of Standard 3 Accreditation Criteria NSQHS

Restrictive Policy Cochrane Review 2005: 29 studies persuasive techniques, 27 restrictive. Restrictive techniques on average 3x more effective than persuasive

10 Steps to Planning a Health Promotion Project 1. Talk to the community 2. Research/Needs assessment 3. Identify target groups 4. Identify stakeholders, partners and networks

5. Writing your plan (goals, objectives, strategies) 6. What are your messages? 7. What resources do you need? 8. Choosing your communication outlets/media 9. Developing a timeline and budget 10. Evaluating the health promotion project

1. Talking to Community Physicians: Average LOS = 3 days “ED just give Ceftriaxone, so if the patient improves it is more difficult to discharge early”. “Surgeons put everyone on Timentin and Metronidazole and ignore us when we tell them they don’t need to” Surgeons:……………………….

2. Research/Needs Assessment: Hospital-wide Antibiotic Appropriateness Survey Medical unit: 51% inappropriate. Broad range of reasons - empiric broad spectrum antibiotics, delayed IV to oral switch, unusual combinations.

Messages

SCGH Antimicrobial Use

FH Antibiogram

apocalypse now…..

Third generation cephalosporins

Antibiograms - Gram negatives AmoxyCefazolinCiprofloxGentTimentin E. coli (24)6/24 (25%)20/24 (83%)23/24 (93%)23/24 (96%)15/24 (62.5%) K. pneumo (2)R2/2 (100%) 23/24 (96%)2/2 (100%) Ps. aeruginosa (2) 2/2 (100%)23/24 (96%)2/2 (100%) A. baumanii (1)1/1 (100%)23/24 (96%)0/1 (0%) C. koseri (1)1/1 (100%)23/24 (96%)1/1 (100%) E. cloacae (2)2/2 (100%)23/24 (96%)1/2 (50%) Salmonella spp (2) 1/2 (50%)

Community acquired pneumonia guideline

Antibiograms - gram positives PenicillinFlucloxacillin S. aureus (16)2/16 (12.5%)11/16 (69%) S. pneumoniae (9)S Group A Strep (4)S Viridans Strep (3)S Group B Strep (2)S Enterococcus sppS

Mechanisms of Implementation ED buy-in - high rates of ED-based compliance Regular education sessions - junior staff orientation ‘Doctor’s Den’ easy access Pharmacist notification Antimicrobial stewardship ‘rounds’ Encourage discussion and consultation

Surgical Antibiotic Use 2/19 patients with intra-abdominal infections received ‘inappropriate’ antimicrobial therapy Cefotaxime/Timentin/Tazocin + Metronidazole 5-8 days IV therapy Surgical patients use 15% bed days, but 42% of 3rd gen cephalosporins NO patients continued surgical prophylaxis post- operatively

Intra-abdominal sepsis

Surgical Ward Part-time general surgeons, VMO model Attended surgical business team meeting VRE outbreak SCGH - HOD motivated to limit broad spectrum antimicrobial use, requested restriction of 3rd Generation Cephalosporins from the Gen Surg ward

Progress

Urinary Tract Infections

Progress…??

NAPS data 2013 Note definition of optimal - ID physician involvement

NAPS 2013 Top 10 commonly used antimicrobials

Ongoing Challenges Increasing medical unit admissions NO increase in pharmacy FTE NO increase in allied health FTE Accreditation requirement