unwanted resistance unintended over use unintended under use unapparent cost inefficiency mrmc...

Unwanted ResistanceUnwanted ResistanceUnintended Over UseUnintended Over UseUnintended Under UseUnintended Under Use

Unapparent Cost InefficiencyUnapparent Cost Inefficiency

MRMC Medical Staff Meeting Presentation October 2010

Jenna Swindler, PharmD and Rick Ervin, MD have no financial relationships to disclose

Antimicrobial Therapy:Antimicrobial Therapy:

Those well known:Those well known:– MRSA, VRE, CONS, C.diffMRSA, VRE, CONS, C.diff

Escalating Newer Mechanisms of Enzyme Related Escalating Newer Mechanisms of Enzyme Related Resistance (CRE collection of GNBs)Resistance (CRE collection of GNBs)– KPC enzymeKPC enzyme

Within the last few months even more new onesWithin the last few months even more new ones– NDM-1 enzyme (travel medicine from India and Pakistan NDM-1 enzyme (travel medicine from India and Pakistan

>> Great Britain, Canada, US)>> Great Britain, Canada, US)– VIM (travel medicine-Greece)VIM (travel medicine-Greece)– 24% of Swedish travelers to Africa, Asia, Indian 24% of Swedish travelers to Africa, Asia, Indian

Subcontinent return home with (multiple drug resistant Subcontinent return home with (multiple drug resistant organism = “MDRO”) colonizationorganism = “MDRO”) colonization

New Mechanisms of ResistanceNew Mechanisms of Resistanceand a collection of new acronymsand a collection of new acronyms

We have seen similar bacteria, We have seen similar bacteria, sensitive to only one or two drugs sensitive to only one or two drugs (toxic (toxic ± ± expensive)expensive)

We have seen deaths from infections We have seen deaths from infections due to multi-drug resistant bacteriadue to multi-drug resistant bacteria

Address our deficiencies by our usual Address our deficiencies by our usual CE initiative for a systemic problem CE initiative for a systemic problem because we cannot remember because we cannot remember everything nor always get timely everything nor always get timely informationinformation

The Fear of a “Post Antibiotic Era”The Fear of a “Post Antibiotic Era”Florence is connected to the worldFlorence is connected to the world

Electronic reminders proposed, developed, and Electronic reminders proposed, developed, and approved by the clinical staff.approved by the clinical staff.– Office EMRs (part of ARRA “meaningful use”)Office EMRs (part of ARRA “meaningful use”)– Hospital Order Entry and DocumentationHospital Order Entry and Documentation– Clinical DSS has started, will improve, but critical Clinical DSS has started, will improve, but critical

medical staff input for our new Sorian hospital medical staff input for our new Sorian hospital information system will be needed. Information information system will be needed. Information promotion versus intrusion and “user fatigue”.promotion versus intrusion and “user fatigue”.

The human approach with trained, adjunctive The human approach with trained, adjunctive professional help with timely, relevant, and useful professional help with timely, relevant, and useful clinical information to provide us.clinical information to provide us.

DSS provides meaningful information; final DSS provides meaningful information; final decision regarding relevance to integrate or decision regarding relevance to integrate or ignore is always by responsible clinical staff.ignore is always by responsible clinical staff.

WhatWhat is Clinical Decision Support for the Medical Staff?is Clinical Decision Support for the Medical Staff?

Discuss increasing antimicrobial Discuss increasing antimicrobial resistanceresistance

Identify methods to decrease Identify methods to decrease resistanceresistance

Define antimicrobial stewardship Define antimicrobial stewardship Identify barriers to stewardshipIdentify barriers to stewardship Identify strategies to enhance Identify strategies to enhance

stewardshipstewardship

PresentationPresentation ObjectivesObjectives

Antimicrobial ResistanceAntimicrobial Resistance:: – the capacity of a microorganism to develop a the capacity of a microorganism to develop a

mechanism that causes the antimicrobial agent to no mechanism that causes the antimicrobial agent to no longer be effectivelonger be effective

Antimicrobial effectiveness is a precious Antimicrobial effectiveness is a precious and limited resource.and limited resource.

Antimicrobials are the only class of Antimicrobials are the only class of medication whose efficacy decreases with medication whose efficacy decreases with wide scale use.wide scale use.

Spellberg B, et al. Clinical Infectious Disease 2008:46;155-64.

The ProblemThe Problem

Boucher HW, et al. Clinical Infectious Disease 2009:48(1);1-12.

National Increasing Incidence of ResistanceNational Increasing Incidence of Resistance

Methicillin Resistant Methicillin Resistant Staph Aureus (MRSA)Staph Aureus (MRSA)

Vancomycin Resistant Vancomycin Resistant Enterococcus (VRE)Enterococcus (VRE)

Extended Spectrum Beta Extended Spectrum Beta Lactamase producers Lactamase producers (ESBLs)(ESBLs)

Pseudomonas & Pseudomonas & AcinetobacterAcinetobacter

Clostridium difficile Clostridium difficile (C.diff)(C.diff)

Resistance in the NewsResistance in the News

OutcomesOutcomes MSSAMSSA

SENSITIVESENSITIVEMRSAMRSA

RESISTANTRESISTANT

MortalityMortality 6.7%6.7% 20.7%20.7%

Hospital Hospital ChargesCharges

$73,165$73,165 $118,414$118,414

Without ARIWithout ARI With ARIWith ARI

LOSLOS 12.812.8 23.823.8

Roberts RR et al Clin Infect Dis 2009; 49:1175-1184Lautenbach E. et al. Infect Control Hosp Epidemol 2006;27(9): 893-900

Impact of Antimicrobial ResistanceImpact of Antimicrobial Resistance

New AntimicrobialsNew Antimicrobials

Combating Antimicrobial ResistanceCombating Antimicrobial Resistance

Boucher HW, et al. Clinical Infectious Disease 2009:48(1);1-12.

New Antimicrobial ApprovalNew Antimicrobial Approval

Fitzgerald S. ACP Hospitalists 2009.

CDC Congress Testimony:“A small but growing subset of gram negative bacteria that cause healthcare associated infections have become resistant to ALL available antimicrobial agents”

ASP Targets

New AntimicrobialsNew AntimicrobialsInfection ControlInfection Control


Hand HygieneHand Hygiene– Soap & Water or Antiseptic Soap & Water or Antiseptic

Alcohol GelAlcohol Gel– When:When:

Entering & Exiting UnitsEntering & Exiting Units Removal of GlovesRemoval of Gloves Before & After Patient Before & After Patient

ContactContact Contact PrecautionsContact Precautions

– Any patient that is infected Any patient that is infected with a Multi-Drug Resistant with a Multi-Drug Resistant Organism (MDRO)Organism (MDRO)

– Gown & Gloves MUST be worn Gown & Gloves MUST be worn when in direct patient contactwhen in direct patient contact

Infection ControlInfection Control

New AntimicrobialsNew AntimicrobialsInfection ControlInfection ControlAntimicrobial StewardshipAntimicrobial Stewardship


A multidisciplinary effort to optimize antimicrobial A multidisciplinary effort to optimize antimicrobial use to improve patient outcomes, ensure cost-use to improve patient outcomes, ensure cost-

effective therapy, and and reduce adverse effective therapy, and and reduce adverse eventsevents

Dellit TH, et al. Clinical Infectious Disease 2007:44;159-177.

AntimicrobialAntimicrobial StewardshipStewardship

Activity of ASP includes:Activity of ASP includes:– Appropriate selection, dosing, route, and Appropriate selection, dosing, route, and

duration of antimicrobial therapyduration of antimicrobial therapy Primary goal:Primary goal:

– Optimize clinical outcomes Optimize clinical outcomes – Minimize unintended consequences of Minimize unintended consequences of

antimicrobial useantimicrobial use Secondary goal:Secondary goal:

– Improve cost efficiencyImprove cost efficiency


EvidenceEvidence BasedBased GuidelinesGuidelines

Core Team Core Team Members:Members:– ID PhysicianID Physician– Clinical PharmacistClinical Pharmacist– Clinical MicrobiologistClinical Microbiologist– Information System Information System

SpecialistSpecialist– Infection Control Infection Control

ProfessionalProfessional– Hospital EpidemiologistHospital Epidemiologist

Collaboration of:Collaboration of:– ASP teamASP team– Infection ControlInfection Control– P&TP&T– AdministrationAdministration– Medical staff and Medical staff and

local providerslocal providers


EvidenceEvidence BasedBased GuidelinesGuidelines

Implement evidence-based Implement evidence-based practicespractices

Joint Commission StandardsJoint Commission Standards

Program Design Program Design – Focus on selected parenteral drugsFocus on selected parenteral drugs

– Automatic stop orderAutomatic stop order– Ongoing Education and FeedbackOngoing Education and Feedback– Exclusion of pharmaceutical Exclusion of pharmaceutical

representatives representatives Institutional Funding:Institutional Funding:

– 1 FTE ASP Clinical Pharmacist1 FTE ASP Clinical Pharmacist– 0.25 FTE physician0.25 FTE physician

Carling P, et al. Infection Control and Hospital Epidemiology 2003:24(9);699-706.

Literature Support for ASPLiterature Support for ASP

Types of Recommendations:Types of Recommendations:– D/C antibiotic therapy after 2-3 days D/C antibiotic therapy after 2-3 days – Streamline (Change from broad-Streamline (Change from broad-

spectrum to narrower-spectrum drug spectrum to narrower-spectrum drug based on cultures and sensitivities)based on cultures and sensitivities)

– IV to PO conversions IV to PO conversions Acceptance of recommendations: Acceptance of recommendations:

– 85% after 6 months 85% after 6 months – 98% after 2 years98% after 2 years



Outcomes Realized:Outcomes Realized:– Decrease in use of parenteral drugs Decrease in use of parenteral drugs – Decreased incidence of:Decreased incidence of:

Clostridium difficile Clostridium difficile diseasediseaseResistant Gram Negative infectionsResistant Gram Negative infections

– Efficiency improved as acquisition costs Efficiency improved as acquisition costs decline by 30% decline by 30%



But what if an active program is eliminated?But what if an active program is eliminated? ASP implemented and active from 2002-08ASP implemented and active from 2002-08

– Pharmacist 0.8 FTE and Physician 0.5 FTE Pharmacist 0.8 FTE and Physician 0.5 FTE Program discontinued in 2009Program discontinued in 2009 Result:Result:

– Abx Expenditures increased by > $1 Abx Expenditures increased by > $1 millionmillion

– Defined Daily Doses (DDD) increasedDefined Daily Doses (DDD) increased

Standiford, et al. Abstract 666. CDC SHEA 5 th Decennial Meeting. March 2010.


Increase Patient Safety & Quality of CareIncrease Patient Safety & Quality of Care Decrease Antimicrobial ResistanceDecrease Antimicrobial Resistance Decrease Nosocomial InfectionsDecrease Nosocomial Infections Decrease Adverse Drug Events “ADEs” Decrease Adverse Drug Events “ADEs” Decrease MortalityDecrease Mortality Cost Savings & Opportunity Cost Cost Savings & Opportunity Cost

AvoidanceAvoidance


Literature Defined Benefits of an ASPLiterature Defined Benefits of an ASP

Initiation of AntimicrobialsInitiation of Antimicrobials– Empiric, Targeted, or a type of Prophylaxis Empiric, Targeted, or a type of Prophylaxis

(Clean “Regular” or Therapeutic)?(Clean “Regular” or Therapeutic)? Response to New DataResponse to New Data

– When, What, If to change based on When, What, If to change based on microbiology results, patient response, etc.?microbiology results, patient response, etc.?

– Narrow therapy based on culture results or Narrow therapy based on culture results or discontinue therapy if not clinically infected ?discontinue therapy if not clinically infected ?

Discontinuation of AntimicrobialsDiscontinuation of Antimicrobials– How long to treat? (Literature improving)How long to treat? (Literature improving)– Prolonged duration contributes to resistance Prolonged duration contributes to resistance

and/or superinfection (e.g. fungal)and/or superinfection (e.g. fungal)

Defined Decision Points of Antimicrobial TherapyDefined Decision Points of Antimicrobial Therapy

Obtain at least “Two Cultures” Obtain at least “Two Cultures” appropriate for the clinical scenarioappropriate for the clinical scenario

Choose no more than “Two Drugs” Choose no more than “Two Drugs” thought appropriate for the clinical thought appropriate for the clinical scenario scenario

Wait no longer than “Two Days” to Wait no longer than “Two Days” to reevaluate initial plan based on clinical reevaluate initial plan based on clinical response, culture results, and other response, culture results, and other studiesstudies

By this time, regimen changes are By this time, regimen changes are frequently needed. Types of possible frequently needed. Types of possible changes to follow.changes to follow.

Appreciated the Antimicrobial Rule of “The Two’s” when not clean prophylaxisAppreciated the Antimicrobial Rule of “The Two’s” when not clean prophylaxis

- Author unknown: cited during Hahnemann Hospital ID Rounds in the Fall of 1970 - Author unknown: cited during Hahnemann Hospital ID Rounds in the Fall of 1970

Antimicrobial resistance & lack of Antimicrobial resistance & lack of new antibioticsnew antibiotics

Methods to decrease resistanceMethods to decrease resistanceAntimicrobial stewardship Antimicrobial stewardship MRMC ASP pilot results & current MRMC ASP pilot results & current

activitiesactivitiesProvider FeedbackProvider Feedback

SummarySummary

Antimicrobial StewardshipAntimicrobial Stewardship

Rick Ervin MD & Jenna Swindler, PharmDRick Ervin MD & Jenna Swindler, PharmDMcLeod Regional Medical CenterMcLeod Regional Medical [email protected]@McLeodHealth.org

843-777-4132843-777-4132

unwanted resistance unintended over use unintended under use unapparent cost inefficiency mrmc...

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