1. antimicrobial stewardship, pharmacy and standard 3.14……. Matthew Rawlins ID pharmacist Royal Perth Hospital June 2014 matthew.rawlins@health.wa.gov.au

2. plan definition why is there a need for stewardship? pharmacy and implementation of an ASP (antimicrobial stewardship program) getting started and ASP components pharmacy resources where to find help

3. definition optimising the selection, dosage and duration of an antimicrobial treatment in order to achieve the best clinical outcome whilst minimising toxicity, antimicrobial resistance selection and cost Paskovaty et al. Int J Antimicrob Agents 2005 MacDougall and Polk. Clin Microbiol Rev 2005 Paterson D. Clin Infect Dis 2006 (Suppl) Dellit et al. Clin infect Dis 2007 TG: antibiotic v14 (2010) ACSQHC 2011

5. international benchmarking NAUSP Annual Report 2012-2013

6. stewardship – where to start? ACSHC publication and executive support “pink book” (TG: antibiotic) –local guidelines where necessary antimicrobial formulary and restriction measuring use (before you start and as you go) –NAPS –NAUSP antibiograms rounds

7. Australia - ACSQHC publication Duguid and Cruickshank (Eds). Antimicrobial Stewardship in Australian Hospitals. Australian Commission on Safety and Quality in Healthcare January 2011 Dellit et al. IDSA guidelines CID 2007 –implementation –strategies –resources

8. recommendations for implementation of an ASP (ACSQHC 2011) includes an antimicrobial prescribing and management policy, plan and implementation strategy antimicrobial formulary, guidelines for treatment and prophylaxis according to TG: antibiotic multidisciplinary AST (AS team) »ID physician, clinical microbiologist or lead clinician »pharmacist ASP resides in quality improvement and patient safety structure ASTs links to DTC, IPCC, clinical governance or safety and quality units support and training for AST member roles process and outcome indicators are measured

9. ASP structure

10. antimicrobial stewardship committee (ASC) multidisciplinary membership –ID pharmacist DUE, QUM, “interested” pharmacist(s) role directing appropriate antimicrobial use at institution level TOR chair/membership/reporting aims and objectives

11. executive support (ACSQHC 2011) VRE outbreak RPH 2001 provision of resources (esp. personnel time) accreditation! ACSQHC National Safety and Quality Health Service (NSQHS) Standards. Standard 3: Preventing and controlling healthcare associated infections – Antimicrobial Stewardship “3.14” EQuIP 5

12. strategies (ACSQHC 2011) front end –formulary and approval systems all institution except possibly ICU back end –review and prescriber feedback –point of care interventions all of institution including ICU outcome measures and education measuring performance addressing prescriber education and competency

13. formulary and antimicrobial approval systems (ACSQHC 2011) –restricted list and criteria for use (TG: antibiotic) use by ID/Micro only or clinical specialties with suitable experience traffic light system –antimicrobial approval system telephone/verbal computerised (eDSS) –rapid and targeted review facilitated –expert advice is available 24 hours (on call service A/H)

14. measuring antimicrobial use (ACSQHC 2011) continuous or point-prevalence surveys –before you start and as you go –benchmarking international data national (NAUSP, NAPS) locally –trends within hospital –can they be linked to particular events? »eg. increased ESBL rates –clinical audit of particular units/guidelines

15. NAPS – results National Antimicrobial Prescribing Survey (www.naps.vicniss.org.au)

16. NAPS - results BENCHMARKING DATA

17. NAPS - results

18. antimicrobial use National Antimicrobial Use Surveillance Program (NAUSP) vicki.mcneil@health.sa.gov.au –Business Unit for OBDs –InfoHealth for iPharm reports

19. NAUSP total hospital use NAUSP Annual Report 2012-2013

20. back end review of therapy - RPH stewardship rounds –IV to PO switch –empirical to directed therapy –cessation of therapy –duration of therapy –management advice assessment of clinician acceptance cost savings

21. RAD

22. stewardship rounds identification of patients (on targeted agents) –eDSS –clinician entry/identification –clinical pharmacist entry/identification review of patients (ASA Abstracts 2005/2006/2014, MJA Letter 2012) –ID pharmacist plus ID physician/clinical microbiologist or advanced trainee »“notes/results” review »advice given (notes/verbal/LAN page) »adherence and cost savings quantified advantages –visible presence, appreciated by junior medical staff disadvantages –time consuming, occasional senior staff opposition

23. measuring the performance of ASP’s (ACSQHC 2011) –monitoring antimicrobial use –impact of stewardship rounds »number of rounds/patients seen »acceptance of advice given »75-94% Paskovaty et al. Int J Antimicrob Agents 2005 »74-89% Cairns et al MJA 2013, Rawlins et al. ASA Abstracts 2014 »cost savings –ACSQHC Clinical Care Standards and clinical indicators »auditing process indicators »timely surgical prophylaxis, restricted antimicrobial prescribing, CAP treatment, aminoglycoside use (NSWTAG) time to first antibiotic interpretation –of usage data with infection control and resistance data

24. ASR - all advice ASA Abstracts 2014

25. ASR – cost savings ASA Abstracts 2014

26. antimicrobial use – cost savings –institution (formulary decisions) –unit (guidelines containing antimicrobials) –patient level (rounds) compare what was done to what would have been done –approximately $120-240 per patient (ASA Abstracts 2014) –institution unit costs and DDD’s/patient days can be significantly reduced by an ASP (Standiford et al. Infect Control Hosp Epidemiol. 2012)

27. antimicrobial use measuring the impact antimicrobial use time-series analysis compare rate of increase before and after the stewardship intervention(s) ratio of narrow-spectrum to broad-spectrum agents (eg. 1 st /2 nd versus 3 rd/ 4 th generation cephalosporins) David Andresen ASA 2013

28. education and competency of prescribers (ACSQHC 2011) institutional/unit level –grand rounds »overall program or specific interventions –team meetings »ICU meropenem use –stakeholder involvement in guideline development patient/case level –stewardship rounds, clinical pharmacists guidelines for industry

29. antimicrobial resistance Ibrahim and Polk Expert Rev Anti-infect Ther. 2012 Davis et al. ASA Abstracts 2012 Patel et al. Exp Rev Anti-infect Ther. 2008 can antimicrobial use be linked to clinical outcomes? (“do no harm!”) –mortality –readmission rates –LOS reality is more complex –association between use and resistance can be shown but causality is more difficult to prove decreased resistance and amount of CDI have been proposed

30. role of pharmacy service (ACSQHC 2011) admin/management support critical ID pharmacist co-leader of ASP and activities »education, promotion guideline development, implementation and audit, rounds, formulary, research liaison between ID/micro and pharmacy expert advice (clinical) pharmacist participation point-of-care review and interventions knowledge and enforcement of restrictions referral of cases for ASR review advice and education at patient level

31. IT support (ACSQHC 2011) measuring performance of stewardship programme »development of databases »Smart-phone/tablet applications »electronic prescribing, medical records eDSS –address organisational, social and cultural issues relating to prescribing behaviour during implementation –pharmacist/AST maintenance and support audit support –DUAG or similar –pharmacist rotations, interns, students?

32. smaller hospitals Septimus and Owens CID 2011 (Suppl) consider as menu of interventions which are adaptable to the infrastructure of institutions of any size key elements –management support –effective local champion (even if no on-site ID service) »physician or pharmacist »promote optimal antimicrobial use »interdisciplinary collaboration, antibiotic selection guidance, de- escalation, discontinuation »involve with infection control/prevention activities »pharmacist-led ASPs have been effective at improving antibiotic use –primary outcome aim is to improve patient outcomes not to decrease cost rural and regional requirements (James et al ECCMID 2013) –access to education and implementation tools –model and toolkit being developed role of telemedicine?

33. conclusions –antimicrobial stewardship is here ACSQHC and accreditation –comprehensive ASPs contain many different strategies and require multidisciplinary input determined by institutional size (resources) support from administration is critical –use your (pharmacy) networks

34. assistance ID pharmacy COSP (SHPA) –email discussion group ACSQHC (“the commission”) ASA (Australian Society for Antimicrobials) annual pharmacist workshop NPS (National Prescribing Service) NAUSP, NAPS (usage data) international guidelines and literature –US: IDSA/SHEA/CDC –UK: Antimicrobial Stewardship: Start Smart then Focus: ARHAI