Antimicrobial Stewardship Carrie Poteete MLS(ASCP)cm

Objectives Explain the problem Define Antimicrobial Stewardship Discuss PCAST Explain the presidential executive order Discuss what other states are doing Discuss what is currently being done in Kansas

Threat Report-Current state of affairs Issued September 16, 2013 using data from at least 10 states Threats were assessed according to seven factors related to resistant infections Health impact Economic impact How common is the infection 10-year projection of how common it will become How easily it spreads Availability of effective antibiotics Barriers to prevention http://www.cdc.gov/drugresistance/threat-report-2013

Urgent Threat Clostridium difficile Carbapenem-resistant Enterobacteriaceae (CRE) Drug-resistant Neisseria gonorrhoeae http://blog.labplanet.com/2012/01/27/antimicrobial-sensitivity-testing/ http://www.sciencetimes.com/articles/688/20141012/treating-c-diff-infection-with-oral-frozen-encapsulated-fecal-material.htm

Serious Threats Multidrug-resistant Acinetobacter Drug-resistant Campylobacter Fluconazole-resistant Candida (a fungus) Extended spectrum β-lactamase producing Enterobacteriaceae (ESBLs) Vancomycin-resistant Enterococcus (VRE) Multidrug-resistant Pseudomonas aeruginosa Drug-resistant Non-typhoidal Salmonella Drug-resistant Salmonella Typhi Drug-resistant Shigella Methicillin-resistant Staphylococcus aureus (MRSA) Drug-resistant Streptococcus pneumoniae Drug-resistant tuberculosis http://www.webmd.com/skin-problems-and-treatments/understanding-mrsa

Concerning Threats Vancomycin-resistant Staphylococcus aureus (VRSA) Erythromycin-resistant Group A Streptococcus Clindamycin-resistant Group B Streptococcus www.examiner.com

Threat report-Key points 2 million 23,000 250,000 14,000 $20 billion $35 billion 50% http://www.clipartbest.com/

What is stewardship? “Antimicrobial stewardship refers to coordinated interventions designed to improve and measure the appropriate use of antimicrobials by promoting the selection of the optimal antimicrobial drug regimen, dose, duration of therapy, and route of administration.” “Antimicrobial stewards seek to achieve optimal clinical outcomes related to antimicrobial use, minimize toxicity and other adverse events, reduce the costs of health care for infections, and limit the selection for antimicrobial resistant strains” –IDSA http://www.idsociety.org/Index.aspx

Elements of Stewardship Prospective audits Interventions Feedback

PRESIDENT’S COUNCIL OF ADVISORS ON SCIENCE AND TECHNOLOGY – (PCAST) GOALS (July, 2014) Welcome to the President's Council of Advisors on Science and Technology, known as PCAST. https://www.whitehouse.gov/administration/eop/ostp/pcast

The PCAST report focuses are 3 main area: Improving surveillance of the resistant bacteria Increasing longevity of current antibiotics Increasing the rate in which new antibiotics and other inventions are discovered and delivered http://antibiotic-action.com/aa-resources/

Second Recommendation Effective surveillance and response for antibiotic resistance Strengthen state and local public health infrastructure Increase funding Establish a national surveillance system for resistance based on genomic analysis http://www.philly.com/philly/blogs/public_health/Taxes--thats-right-new-taxes--for-public-health.html

Improve stewardship of existing antibiotics in the health care setting Sixth Recommendation Improve stewardship of existing antibiotics in the health care setting CMS should put reimbursement incentives into place Government funding requirements to drive stewardship Government should lead by example http://www.va.gov/ https://www.cms.gov/

Barriers to Stewardship Higher priority clinical initiatives Staffing concerns Insufficient funding https://bobsnewheart.wordpress.com/2014/10/31/the-greatest-threat-to-your-health/

Presidential Executive Order https://www.whitehouse.gov/about/inside-white-house

Goal 1 Slow the Emergence of Resistance Bacteria and Prevent the Spread of Resistant Infections http://howshealth.com/antibiotic-resistance

Goal 1 Implement public health programs for reporting resistance Foster stewardship programs in all healthcare settings as well as the community http://www.microbioncorp.com/who-report-reveals-global-antimicrobial-resistance-warning/

Goal 1 Education to inform clinicians and the public about stewardship Support public health departments in establishing antimicrobial stewardship programs

Goal 1 Expand collaborative efforts annual reporting Implement annual reporting of antibiotic use Develop and pilot new interventions http://www.ltlmagazine.com/article/groups-commit-responsible-antibiotic-use

one-health surveillance efforts to combat resistance Goal 2 Strengthen national one-health surveillance efforts to combat resistance http://epi.ufl.edu/onehealth/news/

Create regional public health lab network Goal 2 Create regional public health lab network Develop the Detect Network of AR Regional laboratories http://www.google.com/imgres?imgurl=https://lh3.googleusercontent.com/-tqEj5Lo0LdE/AAAAAAAAAAI/AAAAAAAAAAA/K1b6-_tt9q8/s0-c-k-no-ns/photo.jpg&imgrefurl=https://plus.google.com/u/0/103851806558654155503&h=500&w=500&tbnid=-621rCOxqyHHkM:&tbnh=160&tbnw=160&usg=__BqncLM8CvAWhac3-hhLdBfr15OQ=&docid=k4p7Z5aA8YOO7M&itg=1

Goal 2 Formally recognize the Multi-Resistant Organism Repository and Surveillance Network http://wrair-www.army.mil

Goal 2 Link data on susceptibility testing to make it available to local, state, and federal health authorities Submit measures to the National Quality Forum

How do we know stewardship works? Decrease resistant infections: Tertiary care teaching hospital in the surgical and trauma ICU, Charlottsville, VA, USA Instituted an abx cycling program Significant reductions in the incidence of: Antibiotic-resistant GPC infections 7.8/100 vs. 14.6/100 Antibiotic-resistant GNR infections 2.5/100 vs. 7.7/100 Mortality associated with infection 2.9 deaths/100 vs. 9.6 deaths/100 500-bed university affiliated community hospital, Queens, NY, USA Adopted a Restriction based program restricting routine cephalosporin use and requiring primary team to seek ID approval for use 80.1% reduction in hospital-wide cephalosporin use 44% reduction in incidence of ceftazidime-resistant Klebsiella infection and colonization throughout the hospital 70.9% reduction in all intensive care units 87.5% reduction in SICU

How do we know stewardship works? Decrease C. difficle infections: 683-bed, secondary/tertiary-care hospital, Sherbooke, Quebec, Canada Developed guidelines for decreasing antibiotics use associated with Clostridium difficile infections – Creation of educational materials for physicians and pharmacists. Created recommendations to suggest alternative antibiotics for treating conditions. Recommended shorter treatment duration for certain conditions based on IDSA’s guidelines. C. diff incidence decreased 60% between 2003-2004 and 2005-2006, Total and targeted antibiotic consumption decreased 23% and 54% respectively.

How do we know stewardship works? Decrease Cost: 545-bed, state-supported, tertiary-care teaching hospital, Jackson, MS, USA Established restrictions on use of 2nd generation cephalosporins and aminoglycosides requiring obtaining pharmacy approval before drug disbursement Second generation cephalosporin use decreased 52.2%, tobramycin decreased by 75.9% while unrestricted gentamicin increased 229% Reduced expenditures on injectable antibiotics by $193,172.06 during 12 months following restrictions. 175-bed, tertiary-care children's hospital, Baltimore, MD, USA Implemented Electronic Monitoring to provide automated clinical decision support, facilitate approval and allow real-time communication with prescribers related to antibiotics. Reduction in $370,069 in projected, annual cost associated with restricted antimicrobial use 11.6% reduction in doses of restricted antibiotics over one year. User satisfaction improved from 22% to 68% and from 13% to 69% among prescribers and pharmacists respectively.

How do we know stewardship works? Decrease use: 689-bed tertiary care teaching hospital, Omaha, NE, USA Created an order form for surgical antimicrobial prophylaxis   Form use was mandatory but had an "opt out" space on it Increase in patients receiving appropriate antibiotics following intervention (84.9% from 62.3%), Significant improvement in appropriate dosing of antibiotcs for weight (89.9% from 62.1%), Significant increase in appropriate duration of prophylaxis (89.1% from 77.8%).  Mean cost of antimicrobial prophylaxis decreased to $40 per patient from $46 per patient

California http://cafrino.com/california-online-poker-bill-passes-through-committee/ https://www.google.com/search?q=california+public+health&biw=1477&bih=730&source=lnms&tbm=isch&sa=X&sqi=2&ved=0CAgQ_AUoA2oVChMI95ukqc_MxwIVCdOACh3XIwar&dpr=1.3#imgrc=yG7OrxEoNosgYM%3A

Michigan http://www.mi-marr.org https://www.google.com/search?q=michigan&biw=1477&bih=730&source=lnms&tbm=isch&sa=X&sqi=2&ved=0CAcQ_AUoAmoVChMIytmfmdHMxwIVh9KACh2Kvgic#tbm=isch&tbs=rimg%3ACYUZloq2yxYGIjgbHTtzF-BWlmhR5sK_1etjEpXIJXXXzEhixoCiJ4Xf6gBzjyIbIvD-Y8gNgzYKOFT5ru-jpBnvaCSoSCRsdO3MX4FaWEV8I0x1gH2EBKhIJaFHmwr962MQRmYA7w_1rrm1EqEgmlcglddfMSGBGWVrtYiBCCqioSCbGgKInhd_1qAERUljXMkwmzcKhIJHOPIhsi8P5gRP6WXT6tVhnMqEgnyA2DNgo4VPhGodnpEVGeGWCoSCWu76OkGe9oJEfxucxPbD7qV&q=michigan&imgrc=hRmWirbLFgayXM%3A

Oregon http://www.usa4kids.com/flags/Oregon.html https://public.health.oregon.gov/PreventionWellness/SafeLiving/AntibioticResistance/Pages/GetAwarePublications.aspx

https://www. google. com/search https://www.google.com/search?q=kansas&biw=1477&bih=730&source=lnms&tbm=isch&sa=X&sqi=2&ved=0CAcQ_AUoAmoVChMIydzQ1tTMxwIVgriACh3jUQyp#tbm=isch&tbs=rimg%3ACYJkZ-7wPKUbIjg5XBukublhpkNAsreWSQcFm5DqxxOzwy3CGNqIBP7_14s8O4aOrT2tPyfxoaHQ1xY1uoLY_1zR18XSoSCTlcG6S5uWGmEfm2chNgYFWoKhIJQ0Cyt5ZJBwURcNMGYf_16mm0qEgmbkOrHE7PDLREJ6nt2AZ5EBioSCcIY2ogE_1v_1iEeOEGcqVq2PgKhIJzw7ho6tPa08RD7crgqb8gR4qEgnJ_1GhodDXFjRGxB7-tDreRmioSCW6gtj_1NHXxdEcah1YetPHhj&q=kansas&imgdii=zw7ho6tPa0_vrM%3A%3Bzw7ho6tPa0_vrM%3A%3BlCCnOvl5Ua6azM%3A&imgrc=zw7ho6tPa0_vrM%3A http://www.kansas.gov/ http://www.50states.com/flag/ksflag.htm#.VeDJO3BRHF4

Where can Kansas go from here? Track antibiotic use and resistance patterns Establish policies and guidelines for antibiotic use Educate and Evaluate Provide feedback

Thank You! http://eideard.com/2014/10/10/antibiotics-stewardship-reduces-rate-of-hospital-readmission-for-children/