1. Initiating an Antimicrobial Stewardship Program at BC Children's Hospital Quality Forum 2015 Ashley Roberts, MD, M.Ed, FRCP(C) Karen Ng, BSc.Pharm, ACPR, PharmD, BCPS February 19, 2015

2. Disclosures We have no conflicts of interest to declare

3. Goals of Antimicrobial Stewardship Reduce risk of infections Reduce adverse drug events related to antimicrobial use Reduce or stabilize antibiotic resistance Promote patient safety “to optimize clinical outcomes while minimizing unintended consequences of antimicrobial use”

4. BC Children’s Hospital Antimicrobial Stewardship Program 180-bed tertiary care academic hospital and major referral centre for acutely ill or injured children Antimicrobial Stewardship Program implemented September 2013

5. Challenges of Implementing a Pediatric Antimicrobial Stewardship Program (ASP) Limited evidence vs. adult programs for ASP implementation Fragilities of neonatal and pediatric population Limited evidence and treatment guidelines for pediatric infections Pharmacother 2012;32(8):735-743.

6. Key #1 Collaboration “Collective Ownership” Promote Mutual Learning

7. 1. Collaboration Antimicrobial Stewardship Team at BC Children’s and Women’s Hospital ASP MemberRole Dr. Ashley RobertsPHSA AMS Director, Infectious Diseases Specialist Dr. Simon DobsonCo-chair, Infectious Diseases Specialist, Infection Preventionist Dr. Karen Ng Dr. Vanessa Paquette Clinical Pharmacy Specialists Dr. Peter TilleyMedical Microbiologist Dr. Srinivas Murthy Dr. Rod Rassekh Dr. Joseph Ting Pediatric Intensive Care Champion Oncology AMS Champion Neonatal Intensive Care Champion Dr. Roxane CarrPharmacy Clinical Coordinator Form an effective multidisciplinary AMS team of core members.

8. 1. Collaboration Antimicrobial Stewardship Team at BC Children’s and Women’s Hospital ASP MemberRole Dr. Ashley RobertsPHSA AMS Director, Infectious Diseases Specialist Dr. Simon DobsonCo-chair, Infectious Diseases Specialist, Infection Control Dr. Karen Ng Dr. Vanessa Paquette Clinical Pharmacy Specialists Dr. Peter TilleyMedical Microbiologist Dr. Srinivas Murthy Dr. Rod Rassekh Dr. Joseph Ting Pediatric Intensive Care Champion Oncology AMS Champion Neonatal Intensive Care Champion Dr. Roxane CarrPharmacy Clinical Coordinator Form an effective multidisciplinary AMS team of core members. P ARTNERSHIP WITH M ICROBIOLOGY IS E SSENTIAL Antibiogram production Bacterial susceptibility breakpoints tailoring and antimicrobial dose optimization Microbiology reports and comments modifications Implementation of new guidelines/initiatives P ARTNERSHIP WITH M ICROBIOLOGY IS E SSENTIAL Antibiogram production Bacterial susceptibility breakpoints tailoring and antimicrobial dose optimization Microbiology reports and comments modifications Implementation of new guidelines/initiatives

9. 1. Collaboration Antimicrobial Stewardship Team at BC Children’s and Women’s Hospital ASP MemberRole Dr. Ashley RobertsPHSA AMS Director, Infectious Diseases Specialist Dr. Simon DobsonCo-chair, Infectious Diseases Specialist, Infection Control Dr. Karen Ng Dr. Vanessa Paquette Clinical Pharmacy Specialists Dr. Peter TilleyMedical Microbiologist Dr. Srinivas Murthy Dr. Rod Rassekh Dr. Joseph Ting Pediatric Intensive Care Champion Oncology AMS Champion Neonatal Intensive Care Champion Dr. Roxane CarrPharmacy Clinical Coordinator Form an effective multidisciplinary AMS team of core members. I DENTIFY ASP C HAMPIONS Physicians with interest in infectious diseases Promotes collaboration and acceptance of ASP interventions Expands opportunities for research I DENTIFY ASP C HAMPIONS Physicians with interest in infectious diseases Promotes collaboration and acceptance of ASP interventions Expands opportunities for research

10. Example: Partnership with NSQIP (National Surgical Quality Improvement Program) 1. Collaboration

11. Key #2 Optimize Available Resources

12. AMS Pharmacist 12

13. AMS Pharmacist 13

14. Key #2: Optimize Available Resources Teamwork-driven daily prospective audit and feedback Microbiology liaison Infection Control liaison Infectious Diseases team Partnership with clinical pharmacists

15. Key #3 Adapt Strategies to Your Site Understand local culture and attitudes Evaluate “worst offenders” Establish achievable goals

16. Key #3: Adapt Strategies to Your Site Strategies Used/AdoptedStrategies Bypassed Daily prospective audit and feedback Formulary restrictions Dose optimizationAutomatic stop orders Education, development of guidelines and order sets Preauthorization requirements Active surveillance Ongoing research At BC Children’s Hospital:

17. Key #3: Adapt Strategies to Your Site Most ASPs target specific antimicrobials in audit and feedback. BC Children’s Hospital experience: Audit all antimicrobials

18. Reflections and Lessons Learnt Adapting Antimicrobial Stewardship to the Pediatric Population… Reflections and Lessons Learnt Limited evidence requires greater flexibility, discussion and collaboration Continual reassessment and readjustment of ASP strategies and initiatives Must not forget the humanistic factor Data collection and analyses are crucial “from restriction to facilitation” Am J Health Syst Pharm 2011;68:109-10

19. Summary: Keys to Success Initiating an ASP in a Pediatric Hospital 1.Collaboration 2.Optimize available resources 3.Adapt strategies to local culture and attitudes

20. Questions? Ashley Roberts ARoberts6@cw.bc.ca Karen Ng Karen.ng2@cw.bc.ca 604-875-2000 ext 5952 Pager: BCCH Antimicrobial Stewardship