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

2. Declaration of Conflicts of Interest
none

3. 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?

4. 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

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

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

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

8. 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

9. Individual vs. Public Health

10. 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

11. 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

12. Doubles every 2 years

14. 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

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

16. 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

18. Point of Prescription Toolkit
Physician Compact

19. Point of Prescription Toolkit
Physician Compact
Viral Prescription Pads

20. Point of Prescription Toolkit
Physician Compact
Viral Prescription Pads
Patient Education

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

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

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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

30. 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)

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

32. 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…

34. Bacterial Evolution