Transcript Meropenem use at Royal Perth Hospital

antimicrobial stewardship,
pharmacy
and standard 3.14…….
Matthew Rawlins
ID pharmacist
Royal Perth Hospital
June 2014
matthew.rawlins@health.wa.gov.au
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
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
international benchmarking
NAUSP Annual Report
2012-2013
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
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
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
ASP structure
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
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
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
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)
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
NAPS – results
National Antimicrobial Prescribing Survey
(www.naps.vicniss.org.au)
Was the antimicrobial
prescription deemed
appropriate? 2013
0.50%
23.90%
YES
NO
75.60%
NOT
ASSESSABLE
Was the antimicrobial
prescription deemed
appropriate? 2012
YES
0%
33%
NO
67%
NOT
ASSESSABLE
NAPS - results
BENCHMARKING DATA
NAPS - results
Reasons for inappropriate prescriptions 2013 Vs
2012
60
50
40
30
2013
2012
20
10
0
Incorrect Dose or
Frequency
Spectrum Too Broad
Incorrect Duration
Spectrum Too Narrow
Incorrect Route
antimicrobial use
• National Antimicrobial Use Surveillance
Program (NAUSP)
vicki.mcneil@health.sa.gov.au
– Business Unit for OBDs
– InfoHealth for iPharm reports
NAUSP total hospital use
NAUSP Annual Report
2012-2013
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
RAD
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
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
ASR - all advice
100
98
% Adherence
96
94
All Advice
92
90
88
86
84
2004
2005
2011
2012
2013
ASA Abstracts 2014
ASR – cost savings
Cost Savings for Rounds
Cost Saving $ Per Patient
300
250
200
150
100
50
0
2004
2005
2011
2013
Year
ASA Abstracts 2014
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)
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. 1st/2nd versus 3rd/4th generation
cephalosporins)
Ratio of Narrow Spectrum to Broad Spectrum Cephalosporins (outside ICU)
14
12
10
Ratio
8
6
4
2
David Andresen ASA 2013
0
Jul-04
Jul-05
Jul-06
Jul-07
Jul-08
Jul-09
Date
Jul-10
Jul-11
Jul-12
Jul-13
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
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
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
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?
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, deescalation, 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?
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
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