Antimicrobial Stewardship at Swan District Hospital

-A Memoir

Swan District Hospital• 200 bed Secondary General

Hospital

• Obstetrics, Paediatrics

• Emergency Dept

• General Medicine

• 60 beds, 6 high acuity

• General Surgery

• Acute Geriatrics, Stroke, Rehabilitation

• Mental Health, Elderly Mental Health

W.A. AMS ‘Timeline’

• Mid-1990’s SCGH: Multi-resistant Acinetobacter baumanii in ICU.

• Widespread restriction 3rd generation cephalosporins

• 2001: VRE outbreak RPH - $2.4 million to contain. Stimulates RPH AMS Program.

• 2010: 0.5 FTE ID physician and 0.2 FTE pharmacy approved for SDH AMS.

• 2012: AMS part of Standard 3 Accreditation Criteria NSQHS

Restrictive Policy

• Cochrane Review 2005:

• 29 studies persuasive techniques, 27 restrictive.

• Restrictive techniques on average 3x more effective than persuasive

10 Steps to Planning a Health Promotion Project

• 1. Talk to the community

• 2. Research/Needs assessment

• 3. Identify target groups

• 4. Identify stakeholders, partners and networks

• 5. Writing your plan (goals, objectives, strategies)

• 6. What are your messages?

• 7. What resources do you need?

• 8. Choosing your communication outlets/media

• 9. Developing a timeline and budget

• 10. Evaluating the health promotion project

1. Talking to Community

• Physicians:

Average LOS = 3 days

“ED just give Ceftriaxone, so if the patient improves it is more difficult to discharge early”.

“Surgeons put everyone on Timentin and Metronidazole and ignore us when we tell them they don’t need to”

• Surgeons:……………………….

2. Research/Needs Assessment: Hospital-wide Antibiotic Appropriateness Survey

• Medical unit:

• 51% inappropriate.

• Broad range of reasons - empiric broad spectrum antibiotics, delayed IV to oral switch, unusual combinations.

Messages

MessagesSCGH Antimicrobial Use

FH Antibiogram

FH Antibiogram

apocalypse now…..

Third generation cephalosporins

Antibiograms - Gram negatives

Amoxy Cefazolin Ciproflox Gent Timentin

E. coli (24) 6/24 (25%) 20/24 (83%) 23/24 (93%) 23/24 (96%) 15/24 (62.5%)

K. pneumo (2) R 2/2 (100%) 2/2 (100%) 23/24 (96%) 2/2 (100%)

Ps. aeruginosa (2)

2/2 (100%) 23/24 (96%) 2/2 (100%)

A. baumanii (1) 1/1 (100%) 23/24 (96%) 0/1 (0%)

C. koseri (1) 1/1 (100%) 23/24 (96%) 1/1 (100%)

E. cloacae (2) 2/2 (100%) 23/24 (96%) 1/2 (50%)

Salmonella spp (2)

1/2 (50%) 1/2 (50%)

Community acquired pneumonia guideline

Antibiograms - gram positives

Penicillin Flucloxacillin

S. aureus (16) 2/16 (12.5%) 11/16 (69%)

S. pneumoniae (9) S

Group A Strep (4) S

Viridans Strep (3) S

Group B Strep (2) S

Enterococcus spp S

Mechanisms of Implementation

• ED buy-in - high rates of ED-based compliance

• Regular education sessions - junior staff orientation

• ‘Doctor’s Den’ easy access

• Pharmacist notification

• Antimicrobial stewardship ‘rounds’

• Encourage discussion and consultation

Surgical Antibiotic Use

• 2/19 patients with intra-abdominal infections received ‘inappropriate’ antimicrobial therapy

Cefotaxime/Timentin/Tazocin + Metronidazole

5-8 days IV therapy

Surgical patients use 15% bed days, but 42% of 3rd gen cephalosporins

• NO patients continued surgical prophylaxis post-operatively

Intra-abdominal sepsis

Surgical Ward

• Part-time general surgeons, VMO model

• Attended surgical business team meeting

• VRE outbreak SCGH - HOD motivated to limit broad spectrum antimicrobial use, requested restriction of 3rd Generation Cephalosporins from the Gen Surg ward

Progress

Urinary Tract Infections

Progress…??

NAPS data 2013Note definition of optimal - ID physician

involvement

NAPS 2013Top 10 commonly used antimicrobials

Ongoing Challenges

• Increasing medical unit admissions

• NO increase in pharmacy FTE

• NO increase in allied health FTE

• Accreditation requirement