Unwanted Resistance Unintended Over Use Unintended Under Use Unapparent Cost Inefficiency MRMC Medical Staff Meeting Presentation October 2010 Jenna Swindler, PharmD and Rick Ervin, MD have no financial relationships to disclose Antimicrobial Therapy:

 Those well known: –MRSA, VRE, CONS, C.diff  Escalating Newer Mechanisms of Enzyme Related Resistance (CRE collection of GNBs) –KPC enzyme  Within the last few months even more new ones –NDM-1 enzyme (travel medicine from India and Pakistan >> Great Britain, Canada, US) –VIM (travel medicine-Greece) –24% of Swedish travelers to Africa, Asia, Indian Subcontinent return home with (multiple drug resistant organism = “MDRO”) colonization New Mechanisms of Resistance and a collection of new acronyms

 We have seen similar bacteria, sensitive to only one or two drugs (toxic ± expensive)  We have seen deaths from infections due to multi-drug resistant bacteria  Address our deficiencies by our usual CE initiative for a systemic problem because we cannot remember everything nor always get timely information The Fear of a “Post Antibiotic Era” Florence is connected to the world

 Electronic reminders proposed, developed, and approved by the clinical staff. –Office EMRs (part of ARRA “meaningful use”) –Hospital Order Entry and Documentation –Clinical DSS has started, will improve, but critical medical staff input for our new Sorian hospital information system will be needed. Information promotion versus intrusion and “user fatigue”.  The human approach with trained, adjunctive professional help with timely, relevant, and useful clinical information to provide us.  DSS provides meaningful information; final decision regarding relevance to integrate or ignore is always by responsible clinical staff. What is Clinical Decision Support for the Medical Staff?

 Discuss increasing antimicrobial resistance  Identify methods to decrease resistance  Define antimicrobial stewardship  Identify barriers to stewardship  Identify strategies to enhance stewardship Presentation Objectives

 Antimicrobial Resistance : –the capacity of a microorganism to develop a mechanism that causes the antimicrobial agent to no longer be effective  Antimicrobial effectiveness is a precious and limited resource.  Antimicrobials are the only class of medication whose efficacy decreases with wide scale use. Spellberg B, et al. Clinical Infectious Disease 2008:46; The Problem

Boucher HW, et al. Clinical Infectious Disease 2009:48(1);1-12. National Increasing Incidence of Resistance

 Methicillin Resistant Staph Aureus (MRSA)  Vancomycin Resistant Enterococcus (VRE)  Extended Spectrum Beta Lactamase producers (ESBLs)  Pseudomonas & Acinetobacter  Clostridium difficile (C.diff) Resistance in the News

OutcomesMSSASENSITIVEMRSARESISTANTMortality6.7%20.7% Hospital Charges $73,165$118,414 Without ARI With ARI LOS Roberts RR et al Clin Infect Dis 2009; 49: Lautenbach E. et al. Infect Control Hosp Epidemol 2006;27(9): Impact of Antimicrobial Resistance

 New Antimicrobials Combating Antimicrobial Resistance

Boucher HW, et al. Clinical Infectious Disease 2009:48(1);1-12. New Antimicrobial Approval

Fitzgerald S. ACP Hospitalists CDC Congress Testimony: “A small but growing subset of gram negative bacteria that cause healthcare associated infections have become resistant to ALL available antimicrobial agents” ASP Targets

 New Antimicrobials  Infection Control Combating Antimicrobial Resistance

 Hand Hygiene –Soap & Water or Antiseptic Alcohol Gel –When:  Entering & Exiting Units  Removal of Gloves  Before & After Patient Contact  Contact Precautions –Any patient that is infected with a Multi-Drug Resistant Organism (MDRO) –Gown & Gloves MUST be worn when in direct patient contact Infection Control

 New Antimicrobials  Infection Control  Antimicrobial Stewardship Combating Antimicrobial Resistance

A multidisciplinary effort to optimize antimicrobial use to improve patient outcomes, ensure cost-effective therapy, and and reduce adverse events Dellit TH, et al. Clinical Infectious Disease 2007:44; Antimicrobial Stewardship

 Activity of ASP includes: –Appropriate selection, dosing, route, and duration of antimicrobial therapy  Primary goal: –Optimize clinical outcomes –Minimize unintended consequences of antimicrobial use  Secondary goal: –Improve cost efficiency Dellit TH, et al. Clinical Infectious Disease 2007:44; Evidence Based Guidelines

 Core Team Members: –ID Physician –Clinical Pharmacist –Clinical Microbiologist –Information System Specialist –Infection Control Professional –Hospital Epidemiologist  Collaboration of: –ASP team –Infection Control –P&T –Administration –Medical staff and local providers Dellit TH, et al. Clinical Infectious Disease 2007:44; Evidence Based Guidelines

Implement evidence-based practices Joint Commission Standards

 Program Design –Focus on selected parenteral drugs –Automatic stop order –Ongoing Education and Feedback –Exclusion of pharmaceutical representatives  Institutional Funding: –1 FTE ASP Clinical Pharmacist –0.25 FTE physician Carling P, et al. Infection Control and Hospital Epidemiology 2003:24(9); Literature Support for ASP

 Types of Recommendations: –D/C antibiotic therapy after 2-3 days –Streamline (Change from broad- spectrum to narrower-spectrum drug based on cultures and sensitivities) –IV to PO conversions  Acceptance of recommendations: –85% after 6 months –98% after 2 years Carling P, et al. Infection Control and Hospital Epidemiology 2003:24(9); Literature Support for ASP

 Outcomes Realized: –Decrease in use of parenteral drugs –Decreased incidence of:  Clostridium difficile disease  Resistant Gram Negative infections –Efficiency improved as acquisition costs decline by 30% Carling P, et al. Infection Control and Hospital Epidemiology 2003:24(9); Literature Support for ASP

But what if an active program is eliminated?  ASP implemented and active from –Pharmacist 0.8 FTE and Physician 0.5 FTE  Program discontinued in 2009  Result: –Abx Expenditures increased by > $1 million –Defined Daily Doses (DDD) increased Standiford, et al. Abstract 666. CDC SHEA 5 th Decennial Meeting. March Literature Support for ASP

 Increase Patient Safety & Quality of Care  Decrease Antimicrobial Resistance  Decrease Nosocomial Infections  Decrease Adverse Drug Events “ADEs”  Decrease Mortality  Cost Savings & Opportunity Cost Avoidance Dellit TH, et al. Clinical Infectious Disease 2007:44; Literature Defined Benefits of an ASP

 Initiation of Antimicrobials – Empiric, Targeted, or a type of Prophylaxis (Clean “Regular” or Therapeutic)?  Response to New Data –When, What, If to change based on microbiology results, patient response, etc.? –Narrow therapy based on culture results or discontinue therapy if not clinically infected ?  Discontinuation of Antimicrobials –How long to treat? (Literature improving) –Prolonged duration contributes to resistance and/or superinfection (e.g. fungal) Defined Decision Points of Antimicrobial Therapy

 Obtain at least “Two Cultures” appropriate for the clinical scenario  Choose no more than “Two Drugs” thought appropriate for the clinical scenario  Wait no longer than “Two Days” to reevaluate initial plan based on clinical response, culture results, and other studies  By this time, regimen changes are frequently needed. Types of possible changes to follow. Appreciated the Antimicrobial Rule of “The Two’s” when not clean prophylaxis - Author unknown: cited during Hahnemann Hospital ID Rounds in the Fall of 1970

 Antimicrobial resistance & lack of new antibiotics  Methods to decrease resistance  Antimicrobial stewardship  MRMC ASP pilot results & current activities  Provider Feedback Summary

Antimicrobial Stewardship Rick Ervin MD & Jenna Swindler, PharmD McLeod Regional Medical Center