Results from Antimicrobial Stewardship (AMS) Program

Implementation

Somer Smith, PharmD, BCPS, AAHIVP

Disclosures

• Consultant and speaker for Theratechnologiespharmaceutical company

Objectives

• Summarize the core elements of a hospital antimicrobial stewardship program

• Describe initial implementation strategy for an antimicrobial stewardship program and engagement of stakeholders

• Review an antimicrobial stewardship Vancomycin quality improvement strategy and outcomes

• Summarize future directions

The Medical Center - Navicent Health

• 637-bed, Not-for-Profit hospital

• Level 1 Trauma Center (nationally verified)

• Teaching Hospital (Mercer University College of Medicine)

• Beverly Knight Olson Children’s Hospital

• Location- Macon, GA

CDC Core Elements Gap AnalysisProcess Prior to 2019 Process After 2019

Leadership Commitment

Letter from CMO Updated Letter from new CMO, CMO attendance at all ASP meetings, support from CMO and Chief of Systems of Care

integration of Quality in physician newsletter

Accountability ID Physician champion, no full-time ID Pharmacists

ID physician champion and 1 FTE ID Pharmacist

Key Supporters IP, Lab, Intensivists CMO, IP, Lab, Hospitalists, Intensivists, Quality, all ID groups

Stewardship Program Functions

No formal rounds, no binder, quarterly meetings

ASP Binder, prospective audit, quarterly meetings

Guidelines None Empiric Therapy Guidelines

Interventions Restricted antibiotics, Vancomycin 72 hr de-escalation

Prospective Audit Feedback (includes review of restricted antibiotics, patients on antibiotics > 48 hrs, MDROs)

Tracking/Reporting None AUR, Top 10 Antimicrobial Expenditures, MDROs

Education Unit education by pharmacists, emails

Stewardship website, grand rounds, physician newsletter, ICU in-services, system wide emails

Methods

No dedicated prospective audit and

feedback. No dedicated pharmacist. ID physician

led policies.

January 2019:

Gap analysis and implementation of system-

wide ASP

with daily prospective audit feedback

ASP pharmacist communicates real-time

recommendations to clinicians

24 months

2016-2018

Pre- ASP Implementation

February–Current

Post-ASP Implementation

8 months

ASP Intranet Site

Example Goals for 2018 & 2019

• Decrease Vancomycin AUR by 10%

• Decrease C.diff rate

• Increase IV to PO conversion rate by10%

Vancomycin (IV)

• IDSA recommends that ASPs implement guidelines and strategies to reduce antibiotic therapy to the shortest effective duration.

• Currently, no guidelines in place at Navicent Health targeting vancomycin stewardship

• CDC recommendations for preventing vancomycin resistant organisms (VRE, VRSA)

• Guideline development should be part of the hospital's quality-improvement program

IDSA – Infectious Diseases Society of AmericaASP – Antimicrobial Stewardship ProgramVRE – Vancomycin resistant Enterococcus sp.VRSA – Vancomycin resistant Staphylococcus aureus

9

Medical Center - (IV) Vancomycin Consumption

0 100 200 300 400 500

≤ 3

4 to 6

7 to 10

11 to 14

15 to 21

> 21

Patients

Da

ys

of

Th

er

ap

y

Days of Vancomycin Therapy per Patient(January - March 2018)

Annual spend on vancomycin at Navicent Medical Center: $400,000 10

Goal

• Reduce vancomycin usage without compromising care

– Target 10% reduction

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IV Vancomycin Stewardship protocol

• P&T/MEC have approved a protocol allowing pharmacists to discontinue vancomycin therapy after 72 hours in patients who do not meet one of the following criteria:– MRSA positive culture• Documented MRSA infection within previous 12 months• 2 or more positive cultures for methicillin-resistant coagulase-negative

staphylococcus • Same pathogen and source of specimen!

• Enterococcus positive culture • CNS infection • Gram-positive infections in patients with Type 1 allergy (rash, anaphylaxis) to β-

lactams• Febrile Neutropenia• Patients followed by infectious disease or intensivist

• Prescribers will be directed to consult an infectious disease specialist with concerns regarding discontinuation of vancomycin therapy

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How to Approach Patients on Day Three

Does patient meet criteria

for vancomycintherapy per

protocol?

Yes

Continue vancomycin

and clarify stop date

No

Does the patient have alternative

gram positive coverage?

YesDiscontinue vancomycin

after 72 hours

NoDiscuss with

Provider

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Monitoring and Follow-up

• Re-evaluate 6-12 months after implementation

– Evaluate safety and stewardship endpointsProcess Measures Outcome Measures

• Duration of Therapy• Days of Therapy• Compliance with protocol

• Hospital Length of Stay • Expenditures• C. difficile infections or other adverse

events related to antibiotic treatment

*Reproduced from: Barlam TF, Cosgrove SE, Abbo LM, et al. Implementing an antibiotic stewardship program: Guidelines by the Infectious Diseases Societyof America and the Society for Healthcare Epidemiology of America. Clin Infect Dis 2016; 62(10):e51-77, by permission of Oxford University Press on behalfof The Infectious Diseases Society of America. Copyright © 2016 Oxford University Press. Available at: www.idsociety.org.

14

Vancomycin MUE

• 556 patients started on Vancomycin at Navicent Health during May 2019

• 212 were initial orders in the ED

• Retrospective chart review of 100 randomly selected from 212 initial orders from ED

– 14 orders excluded for patients discharged home from ED

– 86 orders included in analysis

Vancomycin MUE

Pa tie n t P o p u la t io n (n = 8 6 )

G e n d e rMa le : 4 5 (5 2% ) Fema le : 4 1 (4 8% )

A g e (ye a rs )

A ve ra g e Me d ia n Ra n g e

6 1 .2 6 3 1 8 – 8 8

Du ra tio n o f Th e ra p y (d a ys) 3 .6 3 1 -1 9

L e n g th o f S ta y (d a ys ) 9 .3 71 -3 4

Vancomycin

Empiric Treatment IndicationBacteremia

2%HAP/VAP/C

OPD Exacerbatio

n23%

CAP8%

Cellulitis/SSTI

13%DFI/DWI/Necrotizing

Fascitis8%

Sepsis33%

Osteomyelitis4%

Other9%

9%

4%

7%

41%

28%

11%

0% 10% 20% 30% 40% 50%

Catheter in place

History of MRSA colonization

Indwelling Hardware

Transfer from nursing home/subacutefacility

Recent prolonged hospitalization(<3months)

Current prolonged hospital stay(>2weeks)transfer

Risk for MRSA (n=46)

Positive Cultures (n=33)15%

13%

9% 9% 9% 9% 9%

6% 6% 6%

3% 3% 3%

Isolated Organisms

Vancomycin 72 Hour De-escalation

• 68 (79%) patients met criteria

– 54 (79%) de-escalated

– 14 (21%) not de-escalated

• 18 (21%) patients did not meet criteria for de-escalation

– 16 (89%) continued

– 2 (11%) vancomycin stopped prematurely

Vancomycin Utilization Month over Month

96.0397.57

99.94

93.38

91.46

95.99

102.51

88.97 89.25

92.23

88.07

90.47 90.64

80

85

90

95

100

105

JAN FEB MAR APR MAY JUN JUL

Day

s o

f Th

erap

y /

10

00

Day

s at

Ris

k

2018 2019

Vancomycin Utilization vs MRSA Rate

0.0

5.0

10.0

15.0

20.0

25.0

80

85

90

95

100

105

Ca

ses

/ 10

,00

0 D

AR

DO

T

/10

00

DA

R

2018-2019

VANCOMYCIN MRSA RATE Linear (VANCOMYCIN)

Top Antimicrobial Expenditures

2018

• Daptomycin $ 483,158

• Vancomycin $454,966

• Avycaz - $145,378

• Ceftaroline $119,937

• Zosyn- $ 71,837

2019 Extrapolated

• Daptomycin $ 440,814

• Vancomycin $187,894

• Avycaz - $99,476

• Ceftaroline $269,660

• Zosyn- $ 120,812

Potential barriers

• Physician resistance

– Broad-spectrum coverage = CYA coverage

– Unfamiliar or uncomfortable with practicing antibiotic stewardship

• Patient is responding to therapy

• Pharmacist resistance

– Reluctant to make recommendations to prescribers, if necessary

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Key Drivers of Existing Program Success

• Strong, engaged program and hospital leadership

• ID physician as key strategic partner

• Interdisciplinary teamwork

• 1 FTE for stewardship pharmacist

• Lab engagement

• De-centralized Clinical pharmacists

Future Directions

2018

• Daptomycin $ 483,158

• Vancomycin $454,966

• Avycaz - $145,378

• Ceftaroline $119,937

• Zosyn- $ 71,837

2019 Extrapolated

• Daptomycin $ 440,814

• Vancomycin $187,894

• Avycaz - $99,476

• Ceftaroline $269,660

• Zosyn- $ 120,812

Future Directions

• Daptomycin-– MUE completed– Prescriber prescribing

patterns– Restricted antimicrobial

• Ceftaroline-– Complete MUE– Restrict?

• Zosyn-– MUE completed– Increase in AKI rate with Zosyn + Vanc

combination– Empiric therapy guidelines and Sepsis

powerplans changed from Zosyn+Vancomycin to Cefepime+Vancomyin

• Automatic IV to PO– Consult list built in Cerner– De-centralized pharmacists to review

consult list daily

THANK YOU

Questions?