Clinical Coordinator Infectious Diseases Kingsbrook Jewish Medical Center A ntimicrobial S tewardship P rograms of I have no conflicts of interest to disclose Conflicts of Interest Declaration ID: 1036556
Download Presentation The PPT/PDF document "The A B C ’s Nicole Ruggiero, Phar..." is the property of its rightful owner. Permission is granted to download and print the materials on this web site for personal, non-commercial use only, and to display it on your personal computer provided you do not modify the materials and that you retain all copyright notices contained in the materials. By downloading content from our website, you accept the terms of this agreement.
1. The ABC’sNicole Ruggiero, PharmD, BCPSClinical Coordinator Infectious DiseasesKingsbrook Jewish Medical CenterAntimicrobialStewardshipProgramsof
2. I have no conflicts of interest to disclose.Conflicts of Interest Declaration2
3. Identify the impact of inappropriate antibiotic therapy on healthcare systemsDefine antimicrobial stewardship and discuss the role of Antimicrobial Stewardship Programs (ASP) Investigate Joint Commission Standard and CDC guidance on core elements of ASPEvaluate and apply ASP metrics and tools Objectives3
4. Prompt initiation of antibiotic therapy for treatment of infections reduces morbidity and mortality20-50% of all acute care antibiotics prescribed in the US is unnecessary or inappropriate11 million courses of antibiotics dispensed to outpatients in US in 20142Background4CDC. Antimicrobial Resistance. 2017.Hicks LA.Clin Infect Dis. 2015 May 1;60(9):1308-16.
5. 5Antibiotic Use 2014
6. Bacterial Resistance1:2 million infections annually700,000 deaths annuallyProjected increase to 10 million/yr by 2050Clostridium difficile infection (CDI)2:½ million infections annually29,000 deaths annuallyCosts $4.8 billion/yr Epidemiology6CDC. Antibiotic resistance threats in the US. 2013. Lessa FC. New Engl J Med. 2015 February 26; 372:825-834.
7. Antibiotic Resistance of Escherichia coli in the United States7
8. Coordinated interventions designed to improve and measure the appropriate use of antimicrobialsPromotes the selection of:Optimal antimicrobial drug regimenDoseDuration of therapyRoute of administrationWhat is ASP?8
9. Optimize treatment of infectionsIncrease cure ratesReduce treatment failureIncrease frequency of correct prescribingReduce healthcare costReduce adverse events associated with antibiotic useReduce CDI ratesReduce antibiotic resistanceGoals of ASP9
10. Regulatory Aspects of ASP
11. Joint Commission Standard effective January 1, 2017Standard MM.09.01.01 Applies to hospitals, critical access hospitals, and nursing care centersSupported by CMS, CDC, SHEAJC standard for ambulatory care and office based surgery practices still in developmentNew Antimicrobial Stewardship Standard11APPROVED: New Antimicrobial Stewardship Standard. Jt Comm Perspect 2016; 36: 3-4,8.
12. Hospitals/Critical Access Hospitals12
13. Leadership Support13
14. Formal statement of facility supportIncluding stewardship-related duties in job descriptionsEnsuring sufficient time to contribute to stewardship activitiesTraining and EducationAll of the aboveHow can leadership support for ASP be established?14
15. All house staff and independent practitioners involved in ordering antibioticsEducation at time of hire and periodically thereafterEducational competenciesFace to face interactionsStaff Education15
16. Seven-step mentoring program on ASP completed at 6 hospitals16Goff D. Am J Health-Syst Pharm. 2017 Jan 15;74(4):224-231.
17. 17Goff D. Am J Health-Syst Pharm. 2017 Jan 15;74(4):224-231.
18. Patient Education18CDC. Get Smart About Antibiotics Week. 2017
19. CDC Core Elements of ASP19CDC. Core Elements of Hospital Antibiotic Stewardship Programs. 2017
20. Should have input from a multidisciplinary teamRestricted/protected antibiotic systemClinical PathwaysUtilize information technology systemsRapid diagnosticsPolicy and Protocol Development20
21. 21
22. 22
23. Measure impact of ASPAntimicrobial measuresMicrobial measures Provide benchmarking toolsMaintain administrative supportData Analysis23
24. Defined daily dose Days of therapyAntimicrobial-free daysGrams of antimicrobial therapyAntimicrobial cost of therapyAntimicrobial prevalenceLength of stayDisease-specific consumption measuresTargeted antimicrobialsAppropriateness measuresProcess measures24Antimicrobial MeasuresCDC. Core Elements of Hospital ASPs. 2014.
25. Metrics that reflect average amount of antimicrobials being consumed Defined Daily Doses (DDD)Days Of Therapy (DOT)Consumption Measures25
26. Assumed average maintenance dose per day for a drug used for its main indication in adults26Defined Daily DosesWorld Health Organization. ATC Index with DDDs. 2004
27. AntibioticWHO-Assigned DDDClinical Practice DoseCefepime2 grams2-6 gramsPiperacillin14 grams12-16 gramsMeropenem2 grams2-3 gramsVancomycin2 gramsWeight based dosing27WHO-Assigned DDDWorld Health Organization. ATC Index with DDDs. 2004
28. Assumes routine dosingHigher doses overestimatesWeight-based dosing not accurately reflectedRenal dysfunction underestimates1Unit of measurement*Difficult to infer DOT from DDDsDifficult to make conclusions about use of one abx vs another2General Principles of DDD281. Zagorski BM,.Clin Infect Dis. 2002;35(12):1491–7.2. Polk RE.Clin Infect Dis. 2007;44(5):664–70.
29. 0.5123429A patient is admitted to your hospital with Febrile Neutropenia and initiated on cefepime 2g IV q8h. What is the calculated DDD?
30. Considered more clinically relevantSmall hospitals may be unable to calculate DOTs accurately and easilyBiases against combo therapyUseful in weight-based dosing scenariosUsed by the Antimicrobial Use and Resistance ModuleDays Of Therapy30
31. 101520253031A patient receives treatment for a complicated intra-abdomnial infection with vancomycin 1g IV q12h + cefepime 2g IV q12h + flagyl 500mg IV q8h for 10 days. What is the calculated DOT?
32. Measurement MethodAdvantagesDisadvantagesDDDStandardized comparisons of aggregate abx use between hospitalsEstimate use without computerized pharmacy dataDoes not accurately estimate DOTCannot be used in childrenUnderestimated in renal impairmentApproved DDDs subject to changeDOTCan be used in childrenNot influenced by changes in DDDOverestimates in combination therapyDifficult to measure without computerized pharmacy data32Polk RE.Clin Infect Dis. 2007;44(5):664–70.
33. DDDDOTWhich overall measure best reflects the impact of ASPs and their interventions?33
34. IDSA/SHEA 2016 Implementing ASP GuidelinesDOT recommended (weak recommendation, low quality evidence)DDD may be used as an alternativeKey points:Measure appropriateness within your own institution34Which overall measure best reflects the impact of ASPs and their interventions?Barlam TF. Clin Infect Disease. 2016 May 15;62(10):e51-77.
35. Created by the National Healthcare Safety Network (NHSN) Provides a mechanism for facilities to report and analyze antimicrobial use/resistance Two options offered:Antimicrobial use option (AU)Antimicrobial resistance option (AR)35Antimicrobial Use and Resistance (AUR) ModuleCDC. AUR Module. 2017
36. Released in 2011Voluntary reporting and analysis of antimicrobial useRequirements for participation:eMAR or BCMA -and- Ability to collect and package data using HL7 formatting36AU OptionCDC. AUR Module. 2017
37. Numerator: DOTsIncludes 89 antimicrobialsStratified by route of administrationOnly looks at administration dataDenominators:Days present# of days in which a patient spent any time in a specific unit or facilityAdmissions# of patients admitted to an inpatient location in the facility37AU Option- Data ElementsCDC. AUR Module. 2017
38. Provides standardize way to package and upload dataData cannot be entered by hand Monthly uploading of data38Clinical Document Architecture (CDA)CDC. AUR Module. 2017
39. 39https://www.cdc.gov/nhsn/pdfs/training/aur/aur-training.pdf
40. 40AU Option- Analysis ReportsCDC. AUR Module. 2017
41. Metric for comparing observed-to-predicted days of antibiotic therapyUses nationally aggregated AU data to determine predicted DOTAdjusted for bed size, teaching status, ICU status, and ward typeProvides benchmark for comparing your hospitals DOT to others nationally41Standardized Antimicrobial Administration Ratio (SAAR)CDC. Standardized Antimicrobial Administration Ratio (SAAR) Table. 2017
42. 42Interpreting SAARCDC. Standardized Antimicrobial Administration Ratio (SAAR) Table. 2017
43. SAAR ≥ 1 indicates more antimicrobial use than predictedSAAR < 1 indicates antimicrobial use is less than predicted“SAAR alone is not a definitive measure of the appropriateness or judiciousness of antibacterial use, and any SAAR may warrant further investigation” –CDC/NHSN 43Interpreting SAARCDC. Standardized Antimicrobial Administration Ratio (SAAR) Table. 2017
44. Antimicrobial resistance prevalenceResistance ratesAntibiogramsCDI rates44Microbial Measures
45. 45
46. Released in 2014Voluntary reporting of antimicrobial resistance dataRequirements for participation:Electronic Laboratory Information SystemAdmission Discharge Transfer SystemAbility to collect and package data using HL7 formatting46AR OptionCDC. AUR Module. 2017
47. Numerator: Isolate-level susceptibility results for specific organismsPatient specific infoDOB, Gender, Admission Date, LocationSpecimen specific info Collection date, specimen sourceAntimicrobial susceptibility infoSign, value, and interpretation for testLaboratory interpretationDenominator: patient days & admissions47AR Option Data ElementsCDC. AUR Module. 2017
48. 48AR Option- Analysis ReportsCDC. AUR Module. 2017
49. Use data analysis to identify areas for improvementImplement targeted interventions to improve antibiotic useAntibiotic specificDisease Specific49Taking Action
50. ASPs are needed to optimize treatment of infections and to reduce adverse events associated with abx useNew JC standard provides 8 key performance elements for ASPsNumerous metrics and tools available for data analysisDo what works for your hospital!Implement targeted interventions to improve outcomes50Conclusions
51. The ABC’sNicole Ruggiero, PharmD, BCPSClinical Coordinator Infectious DiseasesKingsbrook Jewish Medical CenterAntimicrobialStewardshipProgramsofQuestions?Nruggiero@kingsbrook.org
52. Centers for Disease Control and Prevention. Antimicrobial Resistance. Available at: https://www.cdc.gov/drugresistance/. Accessed March 2017.Hicks LA, Bartoces MG, Roberts RM, et al. US outpatient antibiotic prescribing variation according to geography, patient population, and provider specialty in 2011. Clin Infect Dis. 2015 May 1;60(9):1308-16.The Center for Disease Dynamics, Economics & Policy. Antibiotic Use. Available at: https://resistancemap.cddep.org/AntibioticUse.php. Accessed February 2017.Centers for Disease Control and Prevention. Antibiotic resistance threats in the United States, 2013. Available at: https://www.cdc.gov/drugresistance/pdf/ar-threats-2013-508.pdf. Accessed February 2017.Lessa FC, Mu Yi, Bamberg WM, et al. Burden of Clostridium difficile Infection in the United States. New Engl J Med. 2015 February 26; 372:825-834.The Center for Disease Dynamics, Economics & Policy. Antibiotic Resistance. Available at: https://resistancemap.cddep.org/AntibioticResistance.php. Accessed February 2017. APPROVED: New Antimicrobial Stewardship Standard. Jt Comm Perspect 2016; 36: 3-4,8. Goff DA, Karam GH, Haines ST. Impact of a national antimicrobial stewardship mentoring program: Insights and lessons learned. Am J Health-Syst Pharm. 2017 January 15;74(4):224-231.Centers for Disease Control and Prevention. Get Smart About Antibiotics Week. Available at: https://www.cdc.gov/getsmart/week/. Accessed March 2017. 52References
53. Centers for Disease Control and Prevention. Get Smart About Antibiotics Week. Available at: https://www.cdc.gov/getsmart/week/. Accessed March 2017.CDC. Core Elements of Hospital Antibiotic Stewardship Programs. Atlanta, GA: US Department of Health and Human Services, CDC; 2014. Available at http://www.cdc.gov/getsmart/healthcare/ implementation/core-elements.html.Morris A. Antimicrobial Stewardship Programs: Appropriate measures and metrics. Current Treatment Options in Infectious Diseases. 2014. 6:101-112.World Health Organization. ATC Index with DDDs. Available at: https://www.whocc.no/atc_ddd_index/. Accessed February 2017.Zagorski BM, Trick WE, Schwartz DN, et al. The effect of renal dysfunction on antimicrobial use measurements. Clin Infect Dis. 2002;35(12):1491–7. Polk RE, Fox C, Mahoney A, Letcavage J, MacDougall C. Measurement of adult antibacterial drug use in 130 US hospitals: comparison of defined daily dose and days of therapy. Clin Infect Dis. 2007;44(5):664–70.Barlam TF, Cosgrove SE, Abbo LM, et al. Implementing an Antibiotic Stewardship Program: Guidelines by the IDSA and SHEA. Clin Infect Disease. 2016 May 15;62(10):e51-77.Centers for Disease Control and Prevention. AUR Module. Available at: https://www.cdc.gov/nhsn/pdfs/pscmanual/11pscaurcurrent.pdf . Accessed January 2017.Centers for Disease Control and Prevention. Standardized Antimicrobial Administration Ratio (SAAR) Table. Available at: https://www.cdc.gov/nhsn/pdfs/ps-analysis-resources/aur/au-qrg-saartables.pdf. Accessed March 2017.53