1. Trends and Best Practice for Reducing MDROs
Rachel Long MT (ASCP) M Ed. CIC
Senior Consultant, Clinical Operations
MedMined® services, BD
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2. Review Recent Newsmakers Discuss Some Confounders
Objectives
Review Recent Newsmakers
Discuss Some Confounders
Bring It All Together
·        

3. The Problem

4. Dried Up Pipeline
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5. Pathogens Categorized
Urgent Threats
Clostridium difficile
Carbapenem-resistant Enterobacteriaceae (CRE)
Drug-resistant Neisseria gonorrhoeae
Concerning Threats
Vancomycin-resistant Staphylococcus aureus (VRSA)
Erythromycin-resistant Group A Streptococcus
Clindamycin-resistant Group B Streptococcus
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
The Threat Report is a must read for background on today’s MDRO’s.
I highlight this report because it is a fabulous reference guide for many of the bad bugs today. The graphs are great as well as the information. Much of it is in “bite sizes” just right for clinical consumers.
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6. Other Notable Publications/ Webinars/Meetings
MDRO

7. Two “Recent” Vital Signs on MDRO’s Stewardship

8. Core Elements of Stewardship Programs

9. New Isolation Guidelines for Visitors
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10. Whitehouse June Forum
June…historic step towards reducing antibiotic use
The White House hosts a forum on curbing antibiotic resistance with government, business, and agricultural leaders.
This has been the year for Stewardship in the news….from Whitehouse Forum
4 Strategies:
1. Infection prevention
2. Accurate and prompt diagnosis & treatment
3. Prudent use of antimicrobials
4. Prevention of transmission.

11. Targets
Some of these goals would be great goals to consider in the hospital or IP program /stewardship program as a whole.
Note they line up with Threat Report pathogens.
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12. The Animal Problem

13. Recent COCA Conference on C difficile and CRE

14. Messaging from COCA

15. HICPAC Presentations Scopes and Stewardship
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16. Antibiotic Stewardship Update Capt. Arjun Srinivasan, MD
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17. Duodenoscope Update
Taken from HICPAC presentation by Coulliette-Salmond DHQP July HICPAC update
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18. Interim Duodenoscope Sampling Algorithm FYI
High Concern Organisms
Low Concern Organisms
>10 CFU <10 CFU
ATP
Outbreak Settings
Non-Outbreak Settings
Informing Patients
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19. Update on Recent Forum Michael Craig, MPP
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20. August Vital Signs
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21. New CMS Tool New IC CMS tool
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22. New CMS Tool
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23. Challenges
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24. Factors that promote MDRO’s
Patient
Environment
Hand Hygiene
MDRO Infection
Colonized Patient
Antimicrobial Stewardship

25. Isolation New Guidelines for Visitors
Isolate patients who get newly developed antibiotics (suggested at ICEID conference)
When to discontinue Isolation?
Pressure to discontinue or move to other forms of isolation
Removing Isolation PPE Competently
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26. Surveillance Cultures
Who?
What?
When?
Where?
How?
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27. “New” CLSI breakpoints (M100-S25) Has your lab implemented these?
Microbiology Changes
Rapid Diagnostics
Genetic Sequencing
Maldi tov
Rapid PCR
“New” CLSI breakpoints (M100-S25)
Has your lab implemented these?
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28. Rapid Diagnostics Is this a CLABSI or not?
Depends….. Gram+, catalase+, facultative diptheroids
Pre MALDI
Lab would probably report at “diptheroid” which is on the NHSN common commensal list.
Not CLABSI
Post MALDI
Excellent ID as Actinomyces Neui, which isn't on any of the NHSN lists, However the organism “Actinomyces spp.
CLABSI
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29. NHSN Definitions/Public Reporting
Inconsistent application of the criteria
Grey areas of Definition
Use of results in metrics and compensation
“Destructive Triangulation”
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30. Guidelines
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31. Outpatient Trends and Attitudes
Most OP clinicians don’t believe their prescribing practices contribute to overuse
Positive treatment recommendation associated with decreased risk of abx prescribing
Resulted in 30% decrease
Signed poster in waiting room and exam rooms indicating pledge to decrease inappropriate antibiotic use
Resulted in 20% decrease

32. More Challenges Testing any diarrhea for C difficile Data hard to get
Urine Cultures in Order sets
Treating colonization
Little interaction with community providers
No knowledge of local susceptibility
Goals aren't aligned
Measure dollars for stewardship
Testing on admit to prove “POA”

33. Stewardship

34. Outpatient Measurement
Caution
Financial Benefit
Outpatient Measurement
CAUTION: Saving money doesn’t always equal quality

35. Basic: Antimicrobial Stewardship Roles
Pharmacy/AS physician
Infection Prevention
Day to day operations
Interventions with prescribers
AS physician
ID physician
Surgeon
Hospitalist
Other interested physician
Prompt ID of MDROs
Compliance with Precautions
Bundles for preventing infections (Urine, blood, respiratory)
Hand Hygiene
Education
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36. Implementing of Stewardship Program
Leadership Support
Financial
Clinical
Picking the Team
Program Leadership
Program Support
Access to Antibiotic Data/benchmarks
Choosing an intervention
Usage data and benchmark data…coming with AU data which will be the first publically reported pharmacy metric.
At this time 116 hospitals have submitted at least 1 month of data to CDC AU module. Some homegrown and 4 vendors have done this.
Make them think here….about their use data….
Can you get benchmarking from a vendor…pharmacy and HAI vendors. How do you know what is too much?
Background;
ASP personnel are encouraged to meet with hospital administrators to establish goals and expected outcome measures, and to obtain adequate authority and resources needed to successfully track and achieve goals. ASPs must understand current outcome measures that hospitals are evaluated against, and periodically reevaluate the needs of the institution and modify goals accordingly. Hospital administrators and key physician and nursing leaders should provide support given that the ASP goals are aligned with The Joint Commission standards, CMS performance measures, and quality metrics proposed by the National Quality Forum, Agency for Healthcare Research and Quality, Leapfrog Group, and others. Stakeholders including healthcare professionals, payers, patients, and the public at large should be informed of new ASP initiatives and associated outcomes. ASPs that position themselves to demonstrate improvements in clinical outcomes (especially decreasing inpatient length of hospitalization, or early
Information technology support is essential in obtaining timely and accurate data. Clinical decision support software can help efficiently find patients who require stewardship team review, prioritize daily stewardship activities, track and organize interventions, and facilitate implementation of specific stewardship initiatives. ASPs are encouraged to seek data mining resources in the form of hospital informatics service or other individuals capable of extracting data from large databases to assist with demonstrating the impact of the ASP on patient outcomes. Process improvement methods such as the Plan-Do-Check-Act model are key to analyzing the designated metrics that allow for continued advancement of the program.

37. Using Antibiogram

38. Klebsiella Only Antibiogram (Mechanism of Resistance)
Bug
Isolates
Abx
Klebsiella (all)
1000 67 99 69 86
K. Pneumo
ESBL producer
300 30 __
(KPC producer)
200 5 83
K. Pneumo( non ESBL or KPC)
500
100 48 88 82

39. MRSA and VRE Only Antibiogram Not including ICU
Bug
Abx
MSSA
____ 87
100 __
Coag Neg Staph 67
MRSA 61
Vanc Susc. Enterococcus 96 89 90
Vanc Resist. Enterotoccus 17 56 45
X% of all S. aureus isolates are MRSA and “X” % of Enterococcus isolates are VRE
Can do this with A. baumanii or other MDRO
If Rifampin on chart— consider indicating if its used alone or not

40. Resistance Rates Compared to Antibiotics
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41. Keep It Simple
Develop a Plan &
Stick to it

42. © 2015 CareFusion Corporation or one of its affiliates
© 2015 CareFusion Corporation or one of its affiliates. All rights reserved.

43. Start with YOUR Risk

44. Ways to Reach Bedside Staff
You Tube
Rounding
Nurse Liaison Program
Use Volunteers to help with office jobs in IP
Observations on floors with prompt feedback
Be a part of their clinical team
Post Data regularly in departments
Bring messaging in simple bite sizes

45. Choosing Where to Start By Problem….
Surgery
VAP/VAE
Analyze the compliance with the following:
Surveillance Culturing
Decolonization for MRSA
Appropriate dosing and re-dosing
Pre-Operative bathing
Surgical Prophylaxis
Blood Cultures in ED
Oral Care on floors
Respiratory Culturing
Appropriate culturing?
Ambulation
Endotracheal suctioning?
Equipment care (sterile water)
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46. Or by Pathogen……. Surgical prophylaxis CAP UTI/ASB
Unnecessary starts? Duration? Narrow therapy?

47. Ideas: Measuring Stewardship
Rates of C. difficile infection
Time to administration of appropriate therapy
Vancomycin Therapy and Blood Culture Contamination
Drugs administered to patients with documented allergies
Multidrug regimens with redundant antimicrobial spectra
Regimens that are either inadequate or excessive
Duration of intensive care and overall hospitalization for patients treated with antimicrobials

48. August Vital Signs

49. Failure is NOT an Option
Post Antibiotic Era?
Cancer Chemotherapy
Complex Surgery
Dialysis
Transplants
Rheumatoid Arthritis

50. Summary Data Relationships Knowledge Observe workflow Collaborate
Standardize
Lead

51. Thank you