Collaboration between microbiologists and clinicians- the key for improved antibiotic stewardship

Dr Nizam DamaniAssociate Medical Director

Infection Prevention and Control Southern Health & Social Care Trust, PortadownSenior Lecturer, Queen’s University, Belfast, UK

.

Wednesday, 2nd October 2013 10.30 – 12.00 am

Outline• Setting the scene• Share our experience of collaborative

approach with the clinicians tosuccessfully implement Antibiotic Stewardship Programme

• Conclusions

Antimicrobial Prescribing FactsRULE of 30

• 30% of all hospitalised inpatients at any given time receive antibiotics; higher in Intensive Care Unit

• > 30% are inappropriate • Up to 30% of all surgical prophylaxis is

inappropriate• Antimicrobials account for >30% of

hospital pharmacy budgets

Consequences of Irresponsible Prescribing

• Inappropriate prescribing impacts on the following: – Cost of antibiotics– Toxicity , side effects and allergies– Emergence of multi-resistant bacteria

MRSA, ESBL,VRE, CRE etc.– Development of secondary infections with

yeasts, and – C. difficile- associated diarrho ea

http://www.cdc.gov/drugresistance/threat-report-2013/

Successful implementation of antibiotic stewardship is more important than

development of new antibiotics

‘The development of new antibiotics without having mechanisms to ensure their

appropriate use is much like supplying your alcoholic patients

with a finer brandy’.

Dennis Maki 1998

Why clinicians make so many mistakes?...1

• Too many antibiotics • Too many pathogens• Complexity of infectious diseases/conditions• Lack of appropriate diagnostic support • Antibiotics are prescribed mostly by junior

doctors who are rotated frequently between wards and/or hospitals

Why clinicians make so many mistakes?...2• Variability over time and place in

– Pathogen prevalence– Antibiotic susceptibilities– Antibiotic formularies– Types of healthcare facilities and

specialised units

• Poor education & training, both at the undergraduate & postgraduate level, and as a result most of the information (esp. about new antibiotics) is provided by pharmaceutical companies

I am really confused !

The main aim of the Antibiotic Stewardship Programme is to use antibiotics responsibly !

ANTIBIOTIC STEWARDSHIP(PROACTIVE: Prevention)

Emergence of multi-resistant microorganisms ,

prevention of super-infection with yeasts , and C. difficile infections

INFECTION PREVENTION AND CONTROL(PREVENTION: Fire Fighting)

Antibiotic Stewardship

PERSUASIVE

• ���� Educational meetings• ���� Local consensus

process in development of guidelines

• ���� Monitoring & feedback on compliance, cost & consumption data

• ���� Antibiotic ward rounds

RESTRICTIVE

• ���� Selective reporting from Laboratory

• ���� Formulary restriction

• ���� Prior authorisation • X Prescription control e.g.

automatic stop order

• ���� Recommend review of antibiotic on a daily basis

Antibiotic Stewardship ProgrammeSouthern Trust, N. Ireland, U.K.

Trusts are groups of hospitals & healthcare facilities under the same

management

New cases of C. difficile (Medical & surgical wards)

Jan-Dec 2008

10-point C.difficile reduction plan(December 2008)

1. Education of all staff2. Early diagnosis 3. Prompt treatment & management 4. Prompt isolation of all patients with contact precautions5. Hand hygiene with compliance monitoring6. Antibiotic stewardship with introduction of

antibiotic ward rounds7. Enhanced environmental cleaning8. Continuous surveillance & audits 9. Opening of temporary isolation ward for C difficile10.Root Cause Analysis of all patients

Antibiotic Stewardship (Adult medical & surgical wards)

• Encourage use of antibiotics responsibly in two acute hospitals• Reduce inappropriate use of antibiotics• Reduce use of broad spectrum antibiotics• Restriction was imposed on the use of:

– Cephalosporins except for treatment of meningitis and epiglottitis or on advice of clinical microbiologists

– Quinolones (e.g. Ciprofloxacin) – Clindamycin– Co-amoxiclav (Augmentin®)– Tazocin was restricted mainly for the treatment of intra-abdominal sepsis

and hospital acquired pneumonias – Meropenem was restricted mainly for treatment of ESBL

• All antibiotic guidelines were revised and new antibiotic pocket guide was developed

Pocket Guide: Annual Update

Antibiotic Ward Rounds• Agreement was achieved with the

– Chief Executive and Medical Director – Associate Medical Director of Medicine and Surgical Directorate

to agree and nominate a clinician (consultant or speciality grade doctor) to participate in weekly antibiotic ward rounds

• Weekly antibiotic ward round was conducted by Antibiotic Management Team (AMT):– Clinical microbiologist– Nominated clinicians – Antibiotic Pharmacist, and– IV nurse home therapy co-ordinator

Antibiotic Management Team (AMT)

IV nurse home therapy co-ordinator

Antibiotic Pharmacist

Clinical Microbiologist Nominated

Clinician

Antibiotic Ward Rounds• Authority was given to the AMT advise to:

– Stop antibiotic(s) if considered inappropriate– Change antibiotic(s)/dose/duration of therapy in view

of culture results and/or clinical condition of the patient

– Recommend change/review antibiotic prescribing if the patient is ill and/or complex or documentation in the notes is poor

• Decision of AMT was documented in the medical notes & also communicated verbally to a member of the clinical team

Antibiotic Stewardship in Hospital

• Antibiotic ward round to look for:• Reason for prescribing - is this documented or not • Appropriateness • Dose and duration• Compliance with the local guidelines • Appropriate de-escalation to narrow spectrum antibiotic(s) • Failure of antibiotic therapy e.g. abscess, infected indwelling

device, viral infections

• Monthly feedback to all consultants, both on complianceand inappropriate prescribing ,through Associate Medical Director and Director of Acute Services

Monthly feedback to individual consultants through Associate Medical Director with copy to Medical Director and Director of

Acute Service

To assess the severity of chest infection

Schedule of Antibiotic ward rounds

How reliable are your compliance data ?

Compliance monitoringby pharmacist on a weekly basis

ANTIBIOTIC COMPLIANCE DATA

Oh, sure they're nice, but are they

real ?"

Antibiotic Ward Rounds

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NO INDICATION CHOICE INAPPROP NO CURB-65

DOSE INAPPROP FREQ INAPPROP

Antibiotic consumption in four Trusts in N. Ireland

All hospitals have compliance rate of >90% which is done by pharmacist on a weekly basis using chart review

Impact of Antibiotic S tewardship

Programme

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Gentamicin Consumption

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Antibiotic Expenditure in the Southern Trust(All adult inpatients)

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Antibiotic Expenditure in The Southern Trust

Total

Start of antibiotic ward rounds

UK £150,000 per month

UK £80,000 per month

Antibiotic Consumption in the Southern Trust and Rate of C. difficile Infections

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C diff LOW RISK MEDIUM RISK HIGH RISK

Medium risk antibiotic group

Start of antibiotic ward rounds

Low risk antibiotic group

High risk antibiotic group

33McCorry A, Damani N. British Journal of Clinical Pharmacy 2010; 2: 341-344.

C. difficile in inpatients2005-2013

Source: Public Health Agency NI

Multi-modal INTERVENTIONSAntibiotic stewardship &

implementation of IPC practices

Reduction in ESBL Blood Stream Infections 2008-12‘A reduction in use of cephalosporins and quinolones can lead to a

reduction in the risk of ESBL-producing coliforms’.French GL. J Antimicrob Chemother 2010;65: (Suppl1): i9.

MRSA rate Jan 2012 – June 13

2008/09 2009/10 2010/11 2011/12 2012/13

MRSA 16 15 11 10 1

Source: Public Health Agency NI

Conclusions…1• ~ 7 % reduction in total use of antibiotics • Consumption of high risk antibiotics was reduced by

75%; this was replaced by cheap and narrow spectrum antibiotics e.g. gentamicin, flucloxacillin, benzylpenicillin

• ~ 80% reduction in use of Cephalosporin • ~ 50% reduction in use of Quinolones • ~ 80 % reduction in C.difficile infection & MRSA

bacteraemias • Reduction in ESBL blood stream infection

Conclusions…2• Active and interactive interventions are more effective

compared to passive approach • Multi-disciplinary antibiotic wards rounds provide interaction

with clinical team, clinical microbiologist and antibiotic pharmacist

• Feedback of data to the individual consultants is essential to:– improve prescribing practice– help sustainability, and – educational tool

• Managerial back-up & commitment is required both from medical & non-medical manager

• For successful implementation, additional resources of the personnel involved in the antibiotic management team is required

Take home message• If a man sees a fly, he aims at it as it

gives him something to think about! • Fly-in-urinal research found this

reduces spillage in the surrounding area by 80% !

• ~ 80% reduction in use of Cephalosporin

• ~ 80% of C. difficile and MRSA bacteraemias were reduced since the introduction of antibiotic stewardship programme combined with IPC measures

Take home message

FOCUS ON TARGET & EXECUTE ! 39

Thank

you

40

McCorry A, Damani N. The British Journal of Clinical Pharmacy, 2010;2:341-44