trends and best practice for reducing mdros rachel long mt (ascp) m ed. cic senior consultant,...

Trends and Best Practice for Reducing MDROs

Rachel Long MT (ASCP) M Ed. CICSenior Consultant, Clinical OperationsMedMined® services, BD

© 2015 CareFusion Corporation or one of its affliates. All rights reserved.

Objectives

• Review Recent Newsmakers

• Discuss Some Confounders

• Bring It All Together

The Problem

© 2015 CareFusion Corporation or one of its affiliates. All rights reserved.

Dried Up Pipeline

Pathogens Categorized

Urgent Threats

1. Clostridium difficile 2. Carbapenem-resistant

Enterobacteriaceae (CRE) 3. Drug-resistant Neisseria gonorrhoeae

Concerning Threats

4. Vancomycin-resistant Staphylococcus aureus (VRSA)

5. Erythromycin-resistant Group A Streptococcus

6. Clindamycin-resistant Group B Streptococcus

Serious Threats

1. Multidrug-resistant Acinetobacter 2. Drug-resistant Campylobacter 3. Fluconazole-resistant Candida (a fungus) 4. Extended spectrum β-lactamase

producing Enterobacteriaceae (ESBLs) 5. Vancomycin-resistant Enterococcus (VRE) 6. Multidrug-resistant Pseudomonas

aeruginosa 7. Drug-resistant Non-typhoidal Salmonella 8. Drug-resistant Salmonella Typhi 9. Drug-resistant Shigella 10. Methicillin-resistant Staphylococcus

aureus (MRSA) 11. Drug-resistant Streptococcus

pneumoniae 12. Drug-resistant tuberculosis

5© 2015 CareFusion Corporation or one of its affiliates. All rights reserved.

Other NotablePublications/Webinars/Meetings

MDRO

Two “Recent” Vital Signs on MDRO’s Stewardship

Core Elements of Stewardship Programs


New Isolation Guidelines for Visitors

Whitehouse June Forum


Targets

The Animal Problem

Recent COCA Conference on C difficile and CRE

Messaging from COCA

HICPAC Presentations

Scopes and Stewardship



Antibiotic Stewardship Update Capt. Arjun Srinivasan, MD

© 2015 CareFusion Corporation or one of its subsidiaries. All rights reserved.

Duodenoscope Update


Interim Duodenoscope Sampling Algorithm FYI

•High Concern Organisms•Low Concern Organisms–>10 CFU <10 CFU • ATP•Outbreak Settings•Non-Outbreak Settings• Informing Patients

http://www.cdc.gov/hai/pdfs/cre/interim-duodenoscope-surveillance-Protocol.pdf


Update on Recent ForumMichael Craig, MPP


August Vital Signs

New CMS Tool

21© 2012 CareFusion Corporation or one of its subsidiaries. All rights reserved.

New CMS Tool

22© 2012 CareFusion Corporation or one of its subsidiaries. All rights reserved.

Challenges


Factors that promote MDRO’s

Colonized Patient

Hand HygienePatient

Environment

24

Antimicrobial Stewardship

MDRO Infection


Isolation

• New Guidelines for Visitors

• Isolate patients who get newly developed antibiotics (suggested at ICEID conference)

• When to discontinue Isolation?

• Pressure to discontinue or move to other forms of isolation

• Removing Isolation PPE Competently


Surveillance Cultures

• Who?

• What?

• When?

• Where?

• How?


Microbiology Changes

• Rapid Diagnostics◦Genetic Sequencing◦Maldi tov◦Rapid PCR

• “New” CLSI breakpoints (M100-S25)◦Has your lab implemented these?


Rapid Diagnostics

Is this a CLABSI or not?Depends….. Gram+, catalase+, facultative diptheroids

1. Pre MALDIo Lab would probably report at “diptheroid” which is on the

NHSN common commensal list.o Not CLABSI

2. Post MALDIo Excellent ID as Actinomyces Neui, which isn't on any of the

NHSN lists, However the organism “Actinomyces spp. o CLABSI

NHSN Definitions/Public Reporting

1. Inconsistent application of the criteria2. Grey areas of Definition3. Use of results in metrics and

compensation 4. “Destructive Triangulation”


Guidelines


Outpatient Trends and Attitudes

Most OP clinicians don’t believe their prescribing practices contribute to overuse

1.Positive treatment recommendation associated with decreased risk of abx prescribing

Resulted in 30% decrease2.Signed poster in waiting room and exam rooms

indicating pledge to decrease inappropriate antibiotic use

Resulted in 20% decrease

More Challenges

• Testing any diarrhea for C difficile• Data hard to get • Urine Cultures in Order sets• Treating colonization• Little interaction with community providers• No knowledge of local susceptibility • Goals aren't aligned• Measure dollars for stewardship • Testing on admit to prove “POA”

Stewardship

Caution

• Financial Benefit

•Outpatient Measurement

•CAUTION: Saving money doesn’t always equal quality

Basic:Antimicrobial Stewardship Roles

Pharmacy/AS physician

• Day to day operations• Interventions with

prescribers

• AS physician◦ ID physician◦ Surgeon◦ Hospitalist◦ Other interested physician

Infection Prevention• Prompt ID of MDROs• Compliance with

Precautions• Bundles for preventing

infections (Urine, blood, respiratory)

• Hand Hygiene• Education


Implementing of Stewardship Program

• Leadership Support◦ Financial◦ Clinical

• Picking the Team• Program Leadership• Program Support

• Access to Antibiotic Data/benchmarks• Choosing an intervention

Using Antibiogram

Urine AD Urine HA

-5%

0%

5%

10%

15%

20%

25%

30%

Pseudomonas Resistant to Imipenem

2007 2008 2009 2010

Klebsiella Only Antibiogram(Mechanism of Resistance)Bug Isolates Abx Abx Abx Abx Abx

Klebsiella (all)

1000 67 99 69 86

K. PneumoESBL producer

300 30 __ 0 0 86

K. Pneumo(KPC producer)

200 5 __ 0 0 83

K. Pneumo( non ESBL or KPC)

500 100 __ 48 88 82

MRSA and VRE Only AntibiogramNot including ICUBug Abx Abx Abx Abx Abx

MSSA ____ 87 100 __ __

Coag Neg Staph

__ 67 100 __ __

MRSA __ 61 100 __ __

Vanc Susc. Enterococcus

96 __ 100 89 90

Vanc Resist. Enterotoccus

17 __ 0 56 45

X% of all S. aureus isolates are MRSA and “X” % of Enterococcus isolates are VRE

Can do this with A. baumanii or other MDRO

If Rifampin on chart— consider indicating if its used alone or not


Resistance Rates Compared to Antibiotics

Q1 2008

Q2 2008

Q3 2008

Q4 2008

Q1 2009

Q2 2009

Q3 2009

Q4 2009

Q1 2010

Q2 2010

Q3 2010

Q4 2010

Q1 2011

Q2 2011

0

5

10

15

20

25

30

35

40

45

50

0.00

0.20

0.40

0.60

0.80

1.00

1.20

1.40

1.60

Quinolone Utilization Compared to C. difficile Rates

Quinolones C. Diff Rates

Days o

f Thera

py p

er

1000 D

ays a

t R

isk

Cases p

er

1000 D

ays a

t R

isk

Keep It Simple

Develop a Plan &Stick to it

Start with YOUR Risk

Ways to Reach Bedside Staff

• You Tube• Rounding • Nurse Liaison Program• Use Volunteers to help with office jobs in IP• Observations on floors with prompt feedback• Be a part of their clinical team• Post Data regularly in departments• Bring messaging in simple bite sizes

Choosing Where to StartBy Problem….

Surgery• Analyze the compliance

with the following:• Surveillance Culturing• Decolonization for

MRSA • Appropriate dosing and

re-dosing• Pre-Operative bathing• Surgical Prophylaxis

VAP/VAE• Blood Cultures in ED• Oral Care on floors• Respiratory Culturing• Appropriate culturing? • Ambulation• Endotracheal

suctioning?• Equipment care (sterile

water)


Or by Pathogen…….

1. Surgical prophylaxis

2. CAP3. UTI/ASB

Unnecessary starts?Duration? Narrow therapy?

Ideas: Measuring Stewardship

1. Rates of C. difficile infection2. Time to administration of appropriate therapy3. Vancomycin Therapy and Blood Culture

Contamination4. Drugs administered to patients with documented

allergies5. Multidrug regimens with redundant antimicrobial

spectra6. Regimens that are either inadequate or excessive 7. Duration of intensive care and overall hospitalization

for patients treated with antimicrobials

August Vital Signs

Failure is NOT an Option

Post Antibiotic Era?

• Cancer Chemotherapy• Complex Surgery• Dialysis• Transplants • Rheumatoid Arthritis

Summary

1. Data2. Relationships3. Knowledge4. Observe workflow5. Collaborate6. Standardize7. Lead

51

Thank you

trends and best practice for reducing mdros rachel long mt (ascp) m ed. cic senior consultant,...

Documents

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