Antimicrobial Stewardship for Laboratorians Richard A. Van Enk, Ph.D., CIC, FSHEA Director, Infection Prevention and Epidemiology Bronson Healthcare Group Kalamazoo, Michigan 1
SPEAKER DISCLOSURE APHL adheres to established standards regarding industry support of continuing education for healthcare professionals. The following disclosures of personal financial relationships with commercial interests within the last 12 months as relative to this presentation have been made by the speaker(s): The speaker has nothing to disclose. 2
Objectives Listeners will understand why antibiotic stewardship programs exist and what they do Listeners will know what laboratory data antibiotic stewardship programs need and be able to supply the information needed by their antibiotic stewardship program 3
Outline What is antimicrobial stewardship? What is the structure and function of an antimicrobial stewardship program? Does antimicrobial stewardship work? How does the laboratory play a role in an antimicrobial stewardship program? What might be the future of antimicrobial stewardship programs 4
What is antimicrobial stewardship? Stewardship: the conducting, supervising, or managing of something; especially the careful and responsible management of something entrusted to one's care Optimizing the use of antimicrobials Optimizes outcomes, minimizes negative consequenses of antimicrobials IDSA guidelines: an activity that promotes: appropriate selection of antimicrobials appropriate dosing of antimicrobials appropriate route and duration of antimicrobial therapy stopping unnecessary therapy 5
Why do we need antibiotic stewardship? Antibiotics are commonly prescribed Up to 300 million courses in the US annually Up to 40% of hospitalized patients At least one course per US citizen per year Between 20% and 50% of all antibiotics prescribed are inappropriate May be completely unnecessary, wrong drug, wrong dose, wrong duration Up to 30% of hospital prescriptions Up to 80% of outpatient prescriptions 6
Why do we need antibiotic stewardship? Suboptimal treatment increases clinical failure Inappropriate antibiotic use causes unintended consequences to the patient Toxicity, dysbiosis of the microbiome Inappropriate antibiotic use causes the emergence of antibiotic resistance in the individual patient and in the population Antibiotic resistance also increases clinical failure Inappropriate antibiotic use is costly There are few new antibiotics in development 7
Three examples of inappropriate prescribing An infection: urinary tract infection; patient treated, but: No culture was done Culture was done but no symptoms present Culture was negative A drug: vancomycin No cultures done Cultures taken but no Gram positive infection Pathogen was susceptible to other agents A process: lack of stop orders or required review Should be daily, required at 48 hours If continued, provider must document the reason 8
Goals 1. Improve clinical outcomes 2. Reduce unintended consequenses of antimicrobials 3. Combat the emergence of antimicrobial resistance 4. Control costs 9
Strategies Initial patient evaluation Education of physicians to recognize infections Proper use of diagnostic tests Initial choice of antimicrobial Evidence-based order sets, local antibiotic activity Optimizing therapy ordering Correct dose and projected duration Frequent assessment and adjustment Optimize based on culture and susceptibility data De-escalation when possible Feedback to assess outcomes 10
Do antimicrobial stewardship programs work? Effective hospital programs have shown to improve patient outcomes and reduce antibiotic costs by 35% Reduce nosocomial C. difficile rates Typically save 1$ million the first year Most programs pay for themselves many times over in drug costs alone Effective programs have resulted in the stabilization and sometimes reduction in rising antibiotic resistance 11
CDC core elements of a hospital stewardship program Leadership commitment Human, financial and technological resources Accountability A single leader Drug expertise Generally a pharmacist Action Team must do something Tracking Prescribing and antibiotic resistance Reporting To prescribers and administration Physician Education 12
Proposed members of the team Core members Pharmacist with infectious disease training Physician (who does not depend on referrals if possible), to promote the program Clinical microbiologist Information systems specialist Infection preventionist or epidemiologist Nice to have Other clinicians (big antibiotic users) Quality Improvement department Nursing 13
Data you need for antimicrobial stewardship Pharmacy information on drug utilization Days of therapy; days of therapy for each drug, regardless of dose (the preferred measure, works for pediatrics, dosage adjustments) Defined daily dose; the maintenance dose per day for a drug used for its main indication in adults (doesn t work for pediatrics) Annual spending on each antibiotic Indication (to determine appropriateness) 14
Data you need for antimicrobial stewardship Laboratory information Identification and susceptibility data on individual patients as quickly as possible Over-all resistance incidence (antibiogram) to design order sets with preferred treatments C. difficile nosocomial incidence (should go down) Nosocomial and community MDRO incidence (drives empiric regimens) Appropriate non-microbiology laboratory tests for patient assessment (procalcitonin, CBC) with costs 15
Data you need to do antibiotic stewardship Outcomes data Interventions made by pharmacist Interventions complied with by the provider Cost (often savings) of the intervention (to document the return on investment) Group and individual provider reports to administration for identifying opportunities for improvement or outstanding performance (peer group pressure is a powerful change agent for physicians) 16
How can the laboratory play a role in antimicrobial stewardship? Any laboratory test or process that allows clinicians to more quickly diagnose and optimize the therapy of infectious diseases and rule out non-infectious conditions helps antimicrobial stewardship It is just as important to rule out an infection; then you can stop antibiotics Look at your microbiology processes to implement Lean engineering Remove delays, barriers, non-value added steps 24/7 microbiology is your aspirational goal 17
IDSA recommendations for microbiology laboratories to support stewardship 1. Use current CLSI susceptibility testing and reporting procedures Selective and strategic antibiotic reporting and prioritization based on stewardship goals Give treatment suggestions as part of the culture report 2. Implement molecular diagnostics and automation for faster results Faster results allow faster optimization and faster discontinuation of unnecessary treatment 18
IDSA recommendations for microbiology laboratories to support stewardship 3. Antibiotic activity summaries (antibiograms) Update annually Provide focused unit-specific and separate outpatient from inpatient data 4. Rapid screening for significant resistance that changes therapy (ESBL, VRE, MRSA, CRE) 5. Provide strain-typing service for outbreak investigations 19
Examples of microbiology processes Decision support at test requisition 24/7 microbiology Automated specimen processing Automated microbiology testing with autofiling of results that meet criteria Reporting of preliminary results tied to actionable steps (Gram stain, culture) Interfacing automated instruments to eliminate data entry (mistakes and delays) New technology that saves time PCR with or without culture MALDI-TOF identifications 20
Examples of microbiology processes Microbiology has traditionally been thought of as being in a circadian rhythm; a 24-hour cycle with work being done only on day shift and overnight incubation between each step We need to reimagine and redesign microbiology as being real-time The overall goal is actionable results in a short a time as possible 21
Administrative and political Make sure you are represented and actively participate in Infection Prevention and Antibiotic Stewardship committees Review and influence order sets Many patients management is driven by standing orders based on their initial diagnosis Stop unnecessary laboratory testing that may lead to overtreatment Do-if protocols for urine Work up everything requests Contaminated blood cultures 22
What is the future of antibiotic stewardship? Outpatient antibiotic stewardship Stewardship began as a hospital function, but most antibiotics are prescribed to outpatients Outpatient prescribing is more inappropriate than hospital prescribing and is not being measured Policy Statement by SHEA/IDSA/PIDS Expand stewardship functions designed into electronic health record system with decision support Led currently by Epic External forces are mandating stewardship programs 23
What is the future of antibiotic stewardship? Stewardship by an outside contractor remotely ( telestewardship ), for small hospitals Inclusion of laboratory test utilization as a part of stewardship (laboratory tests are misused too) Inclusion of drugs other than antibacterials (antifungals, antivirals) Use of antibiotic utilization as a core competency for physicians that is part of their compensation 24
What questions do you have? 25