antimicrobial bundle

Antimicrobial Use BundleAntimicrobial Use BundleAn idea whose time has come ?An idea whose time has come ?

Dr. Ashok Rattan,

Chief Executive,

Fortis Clinical research Ltd.,

Adviser,

Religare SRL Diagnostics labs in

Fortis / Escorts Hospitals, Delhi & NCR

Antimicrobial Prescribing Facts

• ~ 1/3 of all hospitalised inpatients at any given time receive antibiotics

• ~ up to 1/3 to ½ are inappropriate • ~ up to 30% of all surgical prophylaxis in inappropriate • Antimicrobials account for upwards of 30% of hospital

pharmacy budgets. Stewardship programmes can save up to 10% of pharmacy budgets.

• Inappropriate and excessive use leads to resistance, C.difficle & other ecological consequences, increased morbidity, mortality, increased cost, increased litigation and reduce quality of life

100

80

60

40

20

0

19801975 1985 1990 1995 20001997

VISAVISA

VREVRE

PRSPPRSP

MRSAMRSA

MRSEMRSEPercentage ofPathogensResistant toAntibiotics

Increasing Incidence of Resistance in the USMRSE, MRSA, VRE, PRSP, GISA

1980-2006

VRSAVRSA

2006

South Atlantic Ocean South Pacific Ocean

North Pacific Ocean

North Atlantic Ocean

Indian Ocean

Arctic Ocean Arctic Ocean Arctic Ocean

North Pacific Ocean

United States of America

U.S.A.

Canada

Mexico

Brazil

U. S. A.

French Polynesia (Fr.)

Argentina Uruguay

Paraguay

Chile

Bolivia

Peru

Ecuador

Colombia

Venezuela

Greenland (Den.)

Iceland

Madagascar

South Africa Lesotho

Swaziland

Mozambique

Tanzania

Botswana Namibia Zimbabwe

Angola

Zaire

Zambia

Malawi

Burundi

Kenya Rwanda Uganda

Congo

Gabon

Somalia

Ethiopia

Sudan

Egypt Libya

Chad Niger

Algeria

Mali Mauritania

Morocco

Finland Norway

Sweden

Turkey

Yemen

Oman Saudi Arabia

Iran China

Mongolia

Russia

India

Indonesia

Malaysia

Australia

Japan

Antarctica

Kazakhstan

Hawaiian Islands

120° 60° 0° 60° 120° 180°

60°

30°

0°

30°

60°

180° 150° 120° 90° 30° 0° 30° 60° 90° 120° 150°

60°

30°

0°

30°

60°

60°

USA34%

Latin America45%

Europe9-54%

Russia40-90%

China34-38%

TaiwanPhilipinesSingapore>20%

Africa>20%

ESBL is world wide in distribution

Multiple sources & references

India30-80%

Geographical Distribution of

KPC-Producers

Frequent Occurrence

Sporadic Isolate (s)

Consequences of antibiotic use

•Clinical cure

•Inhibition of non pathogenic bacteria

•Selection of resistant mutants

•Toxicity / side effects

Antimicrobial StewardshipPrudent use of antibiotics +

Infection control

Clinical cureClinical cure

•Inhibition of non pathogenic bacteria•Selection of resistant mutants

•Toxicity / side effects

Antibiotic Stewardship

• Effective antimicrobial stewardship– Audit & feedback– Guidelines & algorithms– Antibiotic order form– Combination– De escalation– Dose optimization– Parentral oral– Cycling

Antibiotic Stewardship

• Comprehensive Infection control– Managing data and information– Policies & procedures– Regulatory requirements– Employee health– Prevent transmission, investigate

outbreaks– Education & training– Mobilize resources: human & financial

Antibiotic Guidelines

Linear Causation ProcessSingle intervention is effective

e.g. vaccination

Non linear web of causationMultiple intervention required

Four processes working at 88% can summate to as little as 50% likelihood that each patient will experience

100% correct process

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What Is a Bundle?

• A grouping of best practices that individually improve care, but when applied together result in substantially greater improvement.

• Science behind the bundle elements is well established – the standard of care.

• Bundle element compliance can be measured as “ yes/no.”

• “All or none” approach.

What is a bundle ?

• Structured way of improving process of care & patient outcomes

• Small, straight forward set of practices (3 to 5) which when performed collectively, reliably & continuously have been proven to improve patient outcomes

• Data from these frequent measures is fed back to those involved in the procedures

• Reduction in negative actions

• The premise of a bundle: – Reduce variation in practice

– Build a collaborative environment

– Bring about change

– Promote problem solving ability of the staff

Antimicrobial Use Bundle

Initiation bundle:1. 1. Clinical rationale for antibiotic initiation documented

2. 2. Appropriate samples for smear & culture collected & submitted to the laboratory

3. 3. Antibiotic selected according to local policy & risk group

4. 4. Antibiotic ordered as per plan

1. (name, dose, route, frequency & tentative duration)

5. 5. Removal of foreign body or ID, as appropriate, considered


Day 3 bundle:1. 1. Was an antibiotic plan documented

1. (name, dose, route, frequency & planned duration ?)

2. 2. Review of diagnosis after lab reports ?

3. 3. If positive microbiology results, was there any adaptation : streamlining or discontinuation

4. 4. Was IV -> oral switch considered & implemented

5. 5. Were all four above mentioned steps followed ?


For Surgical Prophylaxis:1. 1. Agent selected matches local guidelines for

that operation and for that patient

2. 2. Timing of first dose in 30 min to 1 hour before incision

3. 3. Antibiotic stopped by 24 hours after the pre operative dose

Fortis Hospital Fortis Hospital Antimicrobial Use Bundle Data Collection Form (Summary)Antimicrobial Use Bundle Data Collection Form (Summary)

Fortis Hospital Fortis Hospital Antimicrobial Use Bundle Data Collection Form: InitiationAntimicrobial Use Bundle Data Collection Form: Initiation

Fortis Hospital Fortis Hospital Antimicrobial Use PlanAntimicrobial Use Plan

Fortis Hospital Fortis Hospital Antimicrobial Use Bundle Data Collection Form: Day 3Antimicrobial Use Bundle Data Collection Form: Day 3

Fortis Hospital Fortis Hospital Antimicrobial Use Bundle Data Collection Form (Prophylaxis)Antimicrobial Use Bundle Data Collection Form (Prophylaxis)

Implementation of a care bundle for antimicrobial stewardship

Toth NR et al. Am J Health Syst Pharm 2010; 67: 746 - 749

• 903 bed tertiary care hospital in Michigen• Decided to:

– Employ a trained pharmacist to perform antibiotic audit– Daily monitoring of culture & susceptibility results– Suggest changes to empirical & definitive antimicrobial– Provide educational in service program focused on

hospitals own antibiogram• Study:

– Retrospective control: Sept – Nov 2007– Bundle intervention : Feb – Apr 2008

• Inclusion:– Pts receiving antibiotics admitted into Medical & Surgical wards, 85

antibiotic orders to detect a 20% difference in compliance with beta 0.2 and alpha of 0.05

Implementation of a care bundle for antimicrobial stewardship

Toth NR et al. Am J Health Syst Pharm 2010; 67: 746 - 749

• Compliance with Quality Indicators of Antibiotic Use

Indicator Control Intervention p .

1. Document indication 76 80 0.12

2. Appropriate cultures 70 76 0.09

3. Appropriate empirical 55 65 0.06

4. Appropriate deescalation 41/57 52/58 0.01

5. All indicators concurrently 13 43 <0.001

Impact of standardised review of intravenous antibiotic therapy 72 hours after prescription in two internal medicine wards.

Manuel O, Burnand B, Bady P, Kammerlander R, Vansantvoet M., Francioli P, Zanetti G: Journal of Hospital Infection 2010: 74; 326- 331

• Intervention : 196 patients 204 courses• Control : 226 208• Modification proposed: 93 (46%) of 204 courses

– IV -> Oral switch : 48 (23%)– Discontinuation : 16 (8)– Change antibiotic : 32 (16)– Dose modification : 4 (2)

• Compliance with suggestion: 70 / 93 (75%)• Mean duration : 3.9 + 5.2 days 5 + 6 days• Consumption :• Cost :• Mortality : 11.4 (%) 17.4• Length of stay : 19 + 25 17 + 22

Impact of standardised review of intravenous antibiotic therapy 72 hours after prescription in two internal medicine wards.

Manuel O, Burnand B, Bady P, Kammerlander R, Vansantvoet M., Francioli P, Zanetti G: Journal of Hospital Infection 2010: 74; 326- 331

Other indicators for Other indicators for Antimicrobial StewardshipAntimicrobial Stewardship

• Antimicrobial costsAntimicrobial costs

• Resistant trendsResistant trends

• Days on therapyDays on therapy

• Defined daily DoseDefined daily Dose

Attributable costs of HAI Stone et al AJIC 2005; 33(9): 501-509

Infection Mean Cost

($ US)

SD Minimum Maximum

Surgical Site Infection

25546 39875 1783 134602

BI 36441 37078 1822 107156

VAP 9969 2920 7904 12034

UTI 1006 503 650 1361

Socio-economic burden of hospital-acquired infections (HAIs)

Incidence Duration of Stay

Overall costs Specific costs %

7.8% 11 days GBP 2915 Hospital overheads / capital charges / management

33

Acquired one or

more HAIs whilst

in hospital

2.5 times more than uninfected

2.8 times longer than uninfected

Nursing care Operations/

Consumables

Paramedics/ nurses

Antimicrobials

Others

42

7

6

4

2

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“Whether ‘tis nobler in the mind to suffer the slings and arrows

of outrageous… [prescribing]..

or take to arms against a sea of.. [resistance and diarrhoea]..

and by opposing [irrational antibiotics prescribing]

help end it..”

With apologies to William Shakespeare

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antimicrobial bundle

Health & Medicine