1. Antimicrobial Stewardship
Carrie Poteete MLS(ASCP)cm

2. 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

3. 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

4. Urgent Threat Clostridium difficile
Carbapenem-resistant Enterobacteriaceae (CRE)
Drug-resistant Neisseria gonorrhoeae

5. 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

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

7. Threat report-Key points
2 million
23,000
250,000
14,000
$20 billion
$35 billion
50%

8. 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

9. Elements of Stewardship
Prospective audits
Interventions
Feedback

10. 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.

11. 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

12. 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

13. 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

14. Barriers to Stewardship
Higher priority clinical initiatives
Staffing concerns
Insufficient funding

15. Presidential Executive Order

16. Goal 1
Slow the Emergence of Resistance Bacteria and Prevent the Spread of Resistant Infections

17. Goal 1 Implement public health programs for reporting resistance
Foster stewardship programs in all healthcare settings as well as the community

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

19. Goal 1 Expand collaborative efforts annual reporting
Implement annual reporting of antibiotic use
Develop and pilot new interventions

20. one-health surveillance efforts to combat resistance
Goal 2
Strengthen national
one-health surveillance efforts to combat resistance

21. Create regional public health lab network
Goal 2
Create regional public health lab network
Develop the Detect Network of AR Regional laboratories

22. Goal 2
Formally recognize the Multi-Resistant Organism Repository and Surveillance Network

23. 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

24. 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

25. 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 and ,
Total and targeted antibiotic consumption decreased 23% and 54% respectively.

26. 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, 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.

27. 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

28. California

29. Michigan http://www.mi-marr.org

30. Oregon http://www.usa4kids.com/flags/Oregon.html

31. https://www. google. com/search

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

33. Thank You!