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47th Annual Meeting ҉ August 2-4, 2013 ҉ Orlando, FL

How‐To of Antimicrobial Stewardship:Putting Guidelines into Practice

Laura Smith, PharmD, BCPS (AQ ID)Clinical Pharmacist, Infectious Diseases

Jackson Memorial Hospital, Miami, FL

Disclosure

• I do not have a vested interest in or affiliation with any corporate organization offering financial support or grant monies for this continuing education activity, or any affiliation with an organization whose philosophy could potentially bias my presentation

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Objectives

• Upon completion of this activity, the participant should be able to:

– Describe the impact of antimicrobial stewardship

– Review proposed interventions

– Recognize challenges associated                           with implementation

– Demonstrate practical strategies for success

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Jackson Memorial Hospital

• Tertiary Care

• Academic Medical Center

– University of Miami –Miller School of Medicine

• Diverse patient population

– Transplant, oncology, level 1 trauma, burn

• Antimicrobial Stewardship Program 

– Established in 2003

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Antimicrobial Stewardship

• Goal: Improve patient care

– Optimize clinical outcomes

– Minimize unintended consequences• Toxicity

• Selection of pathogenic organisms

• Emergence of resistance

• Self‐sustaining financially

Dellit TH, et al. Clin Infect Dis. 2007; 44:159‐77.

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Boucher HW. Clin Infect Dis. 2013;56(12):1685–948

Boucher HW. Clin Infect Dis. 2013;56(12):1685–94

Antimicrobial Pipeline

Num

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Boucher HW. Clin Infect Dis. 2013;56(12):1685–94

Antimicrobial Stewardship Strategies

Primary Strategies: 

‐ Prospective audit with feedback

‐ Restriction1) Education

2) Guidelines and Clinical Pathways

3) Antimicrobial Cycling

4) Antimicrobial Order Forms

5) Combination Therapy

6) Streamlining or De‐escalation of Therapy

7) Dose Optimization

8) Parenteral to Oral Conversion

Dellit TH, et al. Clin Infect Dis. 2007; 44:159‐77.

Antimicrobial Stewardship Strategies

Primary Strategies: 

‐ Prospective audit with feedback

‐ Restriction1) Education

2) Guidelines and Clinical Pathways

3) Antimicrobial Cycling

4) Antimicrobial Order Forms

5) Combination Therapy

6) Streamlining or De‐escalation of Therapy

7) Dose Optimization

8) Parenteral to Oral Conversion

Dellit TH, et al. Clin Infect Dis. 2007; 44:159‐77. 12

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Multidisciplinary Team

• Infectious diseases (ID) physician

• ID pharmacist

• Clinical microbiologist

• IT specialist

• Infection control professional 

• Epidemiologist

Dellit TH, et al. Clin Infect Dis. 2007; 44:159‐77.

Multidisciplinary Team

• Infectious diseases (ID) physician

• ID pharmacist

• Clinical microbiologist

• IT specialist

• Infection control professional 

• Epidemiologist

Dellit TH, et al. Clin Infect Dis. 2007; 44:159‐77.

Practice: Anti‐Infective Subcommittee (AIS)

• Subcommittee of P&T– Chairperson: ID physician

– Secretary: ID pharmacist

– Other members

• Pharmacists

– Clinical Staff, Pharmacy Residents

• Physicians

– ID, Surgery, Critical Care, ED, Medicine

• Microbiologist

• Infection Control Practitioner 

Pharmacist Functions of AIS

• Formulary reviews

– New antimicrobials

– Drug class reviews

– Medication Utilization Reviews

• Restriction decisions

• Protocol development

• Shortage resolution

• Dose optimization/dose rounding

• Formulation optimization

‘Low Hanging Fruit’

• Echinocandin formulary review

• Dose optimization– Daptomycin vial = 500 mg

– Voriconazole tablet = 50 mg, 200 mg

– Voriconazole vial = 200 mg

– Voriconazole suspension = EXPENSIVE!

• Frozen bags versus vials

• Automated dispensing machines inventory

• Formulation optimization– IV vancomycin as oral

– IV tobramycin as inhaled

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Formulation Optimization

Le J. Pharmacoth. 2010 Jun;30(6):562‐84.http://online.lexi.com/lco/action/doc/retrieve/docid/patch_f/1802819#f_preparationsGoff DA. CID. 2012;55:587‐92.

Inhalation ONLY

Oral Use ONLY

Formulation Optimization

Le J. Pharmacoth. 2010 Jun;30(6):562‐84.http://online.lexi.com/lco/action/doc/retrieve/docid/patch_f/1802819#f_preparationsGoff DA. CID. 2012;55:587‐92.

Inhalation ONLY

Oral Use ONLY

$286 $47

Formulation Optimization

Le J. Pharmacoth. 2010 Jun;30(6):562‐84.http://online.lexi.com/lco/action/doc/retrieve/docid/patch_f/1802819#f_preparationsGoff DA. CID. 2012;55:587‐92.

Inhalation ONLY

Oral Use ONLY

$140 $5

$286 $47

Preservative Free Tobramycin as Inhalation

$150,000 Annual Savings

Pharmacist Secretary Functions of AIS

• Implement recommendations– Educate pharmacists, physicians, nurses

– Modify computer system

– Evaluate inventory/order entry options

• Oxacillin 1 gm

• Maintain meeting documents

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Education

Education

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35 www.ugotabug.med.miami.edu

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Guidelines and Clinical Pathways

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Antimicrobial Order Forms

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Restriction and Streamlining

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Options for Restriction

• Up‐front

• Back‐end approach

– 48‐72 hours

– Becomes restricted

• CPOE

• Order forms

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On Call Options

• 24/7– Advantage: Requests addressed immediately– Disadvantage: Lack of information, lack of personnel 

On Call Options

• 24/7– Advantage: Requests addressed immediately– Disadvantage: Lack of information, lack of personnel 

• 7 am – 11 pm– Advantage: Covers most approval requests immediately– Disadvantage: Overnight orders, need for personnel

On Call Options

• 24/7– Advantage: Requests addressed immediately– Disadvantage: Lack of information, lack of personnel 

• 7 am – 11 pm– Advantage: Covers most approval requests immediately– Disadvantage: Overnight orders, need for personnel

• Business hours– Advantage: No after‐hours personnel needed– Disadvantage: Numerous medications started without approval, team awaiting 5:00 pm to write orders

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On Call Options

• 24/7– Advantage: Requests addressed immediately– Disadvantage: Lack of information, lack of personnel 

• 7 am – 11 pm– Advantage: Covers most approval requests immediately– Disadvantage: Overnight orders, need for personnel

• Business hours– Advantage: No after‐hours personnel needed– Disadvantage: Numerous medications started without approval, team awaiting 5:00 pm to write orders

Restriction Process

• Up‐front

• Approval by

– ID consult 

– Clinical pharmacist following patient

– ASP

• On call through pager

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Technology: Phone vs Pager???

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VS

Order Entry Pop‐Ups

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Behind the Scenes at JMH

• Who is on call?– ID pharmacist, PGY2 pharmacy residents

– Backup ID physician

• How are approvals communicated?– Approval documented in order entry system

– Attached to patient’s medical record number

– Reports run and managed Monday – Friday

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Pharmacy Order Entry System

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ASP Excel Sheet: Active Orders

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ASP Excel Sheet: Discontinued Prospective Audit with Feedback

• Generally a review at 72 hours

– Cultures final

• Pharmacist/physician

– Review chart

– Assess appropriateness

– Contact primary physician

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Prospective Audit with Feedback

• Advantages– Evaluate therapy real time

• Duration

• Dose

• Indication

• Streamlining

• Disadvantages– Time consuming

– Requires careful review

Dose Optimization

• Renal dosing

• Round to available vial size

• Extended/continuous infusion

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George JM. Pharmacother. 2012;32(8):707–721.

Extended Infusion

• β‐lactam antimicrobials

• Advantages

– Optimize target attainment/patient outcomes

– Possibly decrease amount of drug used

Extended Infusion

64http://openi.nlm.nih.gov/imgs/rescaled512/2391264_cc6818-3.png

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Extended Infusion at JMH

• Meropenem

– 1 gm doses over 3 hours

– 500 mg doses over 30 minutes

• Piperacillin/tazobactam

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Extended Infusion

• Advantages

– Optimize killing

• May improve outcomes

– Possible decrease in drug utilization

• Disadvantages

– Line time

– IV compatibility

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Extended Infusion

• Advantages

– Optimize killing

• May improve outcomes

– Possible decrease in drug utilization

• Disadvantages

– Line time

– IV compatibility

• Key

– NURSING EDUCATION68

IV to PO Conversion

• Simple cost savings initiative 

• Advantages

– Decrease cost without compromise

• Efficacy, safety

– Reduced catheter related infections

– Decreased LOS

– Reduction in workload

– No specialty training needed

69Goff DA. Clin Infect Dis. 2012;55:587‐92.

Benchmarking

• Expenditures

– Fluctuate with cost

• Days of Therapy

– Accounts for census changes

– 500 mg q24h x 1 day = 2 gm q8h x 1 day

• Defined Daily Dose

– Accounts for census changes

– Total grams used

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Levofloxacin

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‐$10,000

$0

$10,000

$20,000

$30,000

$40,000

$50,000

0

500

1000

1500

2000

2500

3000

3500

4000

4500

Q2 2011

Q3 2011

Q4 2011

Q1 2012

Q2 2012

Q3 2012

Q4 2012

Q1 2013

Expenditures

DOT

Series1 Series2

Piperacillin/Tazobactam

72

$0

$50,000

$100,000

$150,000

$200,000

$250,000

0

500

1000

1500

2000

2500

3000

3500

4000

4500

5000

Q2 2011

Q3 2011

Q4 2011

Q1 2012

Q2 2012

Q3 2012

Q4 2012

Q1 2013

Expenditures

DOT

Series1 Series2

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Annual Antimicrobial Expenditures

$0

$2,000,000

$4,000,000

$6,000,000

$8,000,000

$10,000,000

$12,000,000

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Estimated Actual

Am J Health‐Syst Pharm—Vol 70 March 15, 2013

• Anyone!!!

• ID Pharmacy Residency

– Advantage: Additional personnel at a lower cost 

– Disadvantage: Continuous training

• Collaboration with School of Pharmacy

– NOVA Southeastern University

– ID Faculty with practice site at JMH

• Pharmacists, Pharmacy Students / Residents

Who Can Help?

Conclusion

• Collaboration is essential

– Physician support 

• Multifaceted interventions 

– Maintain optimal patient care

– Decrease expenditures

• All healthcare providers play a vital role

47th Annual Meeting ҉ August 2-4, 2013 ҉ Orlando, FL

How‐To of Antimicrobial Stewardship:Putting Guidelines into Practice

Laura Smith, PharmD, BCPS (AQ ID)Clinical Pharmacist, Infectious Diseases

lsmith5@jhsmiami.org