(Pseudo) Antimicrobial Stewardship Program in

a Critical Access Hospital

Presented by Karen Burk RPhClinical Pharmacy Coordinator

Powell Valley Healthcare

Who we are…

• 25 bed Critical Access Hospital in rural Wyoming-also cover another 25 bed CAH 30 miles away

• 4 Full time pharmacists including myself and our pharmacy director

• 3 Full time technicians• 1 Full time secretary

Who we are cont’d…

• 6 Family Practice physicians• 5 OB physicians – 3 are also Family

Practice• 1 Internal Medicine/Pediatrician• 1 Orthopedic surgeon with 1 PA and 1 NP• 1 General surgeon• 1 ER physician-down from 4-locums filling

in

AND…

• ZERO Infectious Disease Specialists

What are the goals of an Antimicrobial

Stewardship Program?

Goals of an ASP

• Improve patient care and health outcomes

oWork with health care practitioners to help each patient receive the most appropriate antimicrobial with the correct dose and duration.

oReduce patient’s length of stayoReduce money spent for patient and

facility

Goals of an ASP cont’d

• Prevent antimicrobial overuse, misuse and abuse

oAvoid unnecessary use of antibiotics. oMinimize the development of resistance

Approaches to Antimicrobial Stewardship

• 2 major approaches:

o Front-end or preprescription approach uses restrictive prescriptive authority• Restrict certain antimicrobials and require prior

authorization

o Back-end or postprescription approach uses prospective review and feedback• Review current antibiotic orders and recommend

to continue, adjust, change or discontinue the therapy based on available microbiology results

How we started• Process of evolution-one step at a time

• Utilized information from previous facilities

• Routinely review list serves such as American Society of Health System Pharmacists. Encourage you to join Mountain-Pacific Quality Health list serve

Developed Pharmacist Driven Protocols

• Aminoglycoside and Vancomycin protocols were developed and approved through the Pharmacy and Therapeutics Committee

o Pharmacist performs all dosing and monitoring of the patient

o Able to order labs as appropriate

Developed Pharmacist Driven Protocols

• Renal dosing of certain medications by the pharmacist as approved by the P&T committee

o 35 medications can be modified based on creatinine clearance

o Able to order labs as appropriate

Hospital Protocols

• Community acquired Pneumonia

o Standards originally were antibiotics within 4 hours of entering the ED but then relaxed to 6 hours

o We kept ours at 4 hours

Physician Standing Orders

• Changed our post op antibiotic order sets to discontinue last prophylactic dose by 23 hours of end of surgery

Monitoring form

• Developed an excel spreadsheet to assist in patient monitoring by the pharmacists

Name MR# Visit # Age Sex Ht (in) IBW (kg) ABW (kg) Adj Wt BSA Date Scr CrCl Base

INR PLT

            -88.00   -52.80 0.00     #DIV/0!    Allergies:    Diagnosis:    

Monitoring: CHF? Post OP Abx? CAP? Lovenox/Arixtra? DVT Proph?         Med rec

 

Anticoag protocol Renal Dosing Intervention                                                 Date:   Scr   mg/dl   INR   Warf. Dose       PLTS        ~CrCl   ml/min                    

   MDRD   ml/min/

1.73 x BSA =                  Notes                                          Ongoing issues/comments                                 Renal Dosing Drugs Dose     Comments                                                                                                                                     Date:   Scr   mg/dl   INR   Warf. Dose       PLTS        ~CrCl   ml/min                    

   MDRD   ml/min/

1.73 x BSA =                  Notes                                          Ongoing issues/comments                                 Renal Dosing Drugs Dose     Comments                                                                                                        

Name MR# Visit # Age Sex Ht (in) IBW (kg) ABW (kg) Adj Wt BSA Date Scr CrCl Base

INR PLT

      97 Male 73 79.90 54   1.67 27-Jan 1.5 21.50   113.00

Allergies: NKDA  

Diagnosis: pneumonia  

Monitoring: CHF? Post OP Abx? CAP? Lovenox/Arixtra? DVT Proph?         Med rec

 

Anticoag protocol Renal Dosing Intervention                    

                             

Date: 1/27/13   Scr   mg/dl  INR   Warf. Dose       PLTS  

 

   ~CrCl   ml/min                  

 

   

MDRD   ml/min/1.73

x BSA =                  

NotesPneumonia, lfts elevated, cr elevated. WBC 15.4 with 83.6% neuts. Was in ER 24 hours ago with sinusitis and sent home on abx and nasal steroids. Has been in a failure to thrive pattern for last several years. Was 220 pounds and now 118. Received 500mg iv levaquin in ER. Will change to 250mg IV daily for renal dosing. Vitals stable. Afeb since admit.No MD notes yet.

 

   

   

   

                          

 

Ongoing issues/commentsCheck for sputum culture

 

                             

Renal Dosing Drugs Dose     Comments                  

Levaquin 250mg IV daily 1st dose 500mg in ER 1/27/13  

       

       

       

                             

                             

Working with Infection Prevention RN

• Excel spreadsheet with basic information on new admits with an infectious process going on

• Work together on antibiogram with Lab and IP RN

Date Comm Hosp LTCC Transf Source Organism Comments

07/06/2011 X ?     UTI pending

pt admit 8/4/11, UA done 8/5/11, likely patient had this UTI prior to admit. Note: patient has a hx of MRSA, wound cultures from our ER end of last month were positive for MRSA

06/30/2011     x   UTI E. Coli Treated w/ Keflex.  Flagyl added for potential C diff.

07/14/2011 x       UTI ?Never did ua before starting. She had confusion so they assumed uti.

07/16/2011 x       Osteomyelitis PseudomonasSensitive to zosyn but this strain is positive for inducible beta lactamase

07/20/2011       x Urine1+ budding yeast & trace bacteria

not treated at this point, culture not set up.  Transferred in from skilled-nursing facility

07/23/2011 x       urine unknown/mixed florapt had a uti before being admitted to the hospital.  Was treated with cipro 500mg bid at home.

7/26-27/11 x       UTI MRSEReceived 2 doses IM rocephin in ER and started on tetracycline for at home

07/29/2011 x       diabetic foot few gram + cocciOn zosyn. Was started on zyvox per ID in regional hospital then changed to zosyn

07/27/2011 x      facial cellulits and shingles mssa on IV acyclovir and zyvox per ID in regional hospital

Learn to think outside the box

Barriers…• NO INFECTIOUS DISEASE PHYSICIAN!• Reasons beyond your control- physician wants to

keep on IV abx so patient can stay in hospital or acute care

• Doctor hangs up on you-chase him down• Doctor is rude to you in front of other health care

professionals-try to deal with it-it’s about the patient

Barriers cont’d

o Drug reps! Luckily banned from our institution

o Lose staffing - hard to maintain standards you have set

Barriers cont’d• One doc thinks should be on antibiotics until the

wound is completely healed• One doc has a treatment failure and refuses to

ever use that antibiotic again• One doc hears about a specific med and only

wants to use that one for everyone and everything

Barriers cont’d

• Pharmacy stats for FTE’s are still based on doses dispensed and not on clinical knowledge

Interventions

• If you didn’t document it - you didn’t do it!

Pharmacist 1st qtr 2011 2nd qtr 2011 3rd qtr 2011 4th qtr 2011

A 321 257 231 420

B 103 70 51 130

C 197 247 127 274

D 52 51 36 19

E 7 22 7 6

F 2 n/a n/a n/a

Intern 20 25 46 n/a

Total (assume $76/intervention) 702 $53,352 672 $51,072 498 $37,848 849 $64,524

Accepted/Denied/Unknown(%) 93/6/1 96/2/2 94/3/3 805/14/30

Anticoagulation related 101 104 63 136

Aminoglycoside/Vancomycin 13 15 11 18

Renal Dosing related 38 28 21 25

CLINICAL INTERVENTIONS

Barriers cont’d

• For clinically relevant antibiogram need at least 30 isolates

• Guess how many times we have 30 isolates in our critical access hospital?

Powell Valley Healthcare Antibiogram 2013 Urine Levels Gram Negative **NOTE:  30 isolates are required for a definitive sample size.  Please take this into account when reviewing the data**

Organism Isolates

A/S = Ampicillin/Sulbactam

 AM = Ampicillin

AUG = Amoxicillin/K Clavulanate

CAX = Ceftriaxone

CFZ = Cefazolin

CP = Ciprofloxacin

CPE = Cefepime

CRM = Cefuroxime

FD =  Nitrofurantoin

GM = Gentamicin IMP = 

LVX = Levofloxacin

P/T = Piperacillin/Tazobactam

T/S = Trimeth/Sulfa

TE = Tetracycline      

E. aerogenes 4 75% 0% 0% 100% 0% 100% 100% 75% 50% 100% 100% 100% 100% 100% 100%      

E. cloacae 6 50% 33% 17% 100% 17% 100% 100% 83% 50% 100% 100% 100% 100% 100% 100%      

E. coli 153 66% 63% 86% 99% 93% 92% 100% 98% 99% 93% 100% 92% 99% 82% 80%      

K. oxytoca 4 75% 0% 100% 100% 75% 100% 100% 100% 100% 100% 100% 100% 100% 75% 100%      

K. pneumoniae 18 100% 0% 100% 100% 100% 100% 100% 100% 61% 94% 100% 100% 100% 94% 89%      

P. Aeruginosa 5       60%   40% 100%     80% 100% 40% 100%          

P. Mirabilis 3 33% 67% 67% 100% 67% 100% 100% 100% 0% 100% 100% 100% 100% 67% 0%      

A. Iwoffii 2                                    

C. amalonaticus 1                                    

C. freundii cplx 1                                    

C. Koseri 1                                    

E. asburiae 1                                    

E. fergusonii 1                                    

Escherichia sp 1                                    

M. morganii 1                                    

S. maltophilia 2                                    

S. marcenscens 1                                    

Powell Valley Care Center Antibiogram 2013 Urine Levels Gram Negative**NOTE:  30 isolates are required for a definitive sample size.  Please take this into account when reviewing the data**

OrganismIsolates

A/S = Ampicillin/Sulbactam

 AM = Ampicillin

AUG = Amoxicillin/K Clavulanate

CAX = Ceftriaxone

CFZ = Cefazolin

CP = Ciprofloxacin

CPE = Cefepime

CRM = Cefuroxime

FD =  Nitrofurantoin

GM = Gentamicin IMP = 

LVX = Levofloxacin

P/T = Piperacillin/Tazobactam

T/S = Trimeth/Sulfa

TE = Tetracycline  

E. Coli 5 20% 20% 80% 100% 100% 40% 100% 80% 100% 100% 100% 40% 100% 100% 100%  

K. pneumoniae 5 100% 0% 100% 100% 100% 100% 100% 100% 40% 100% 100% 100% 100% 80% 80%  

P. Mirabilis 3 100% 0% 100% 100% 100% 0% 100% 100% 0% 33% 100% 0% 100% 0% 0%  

K. oxytoca 1                                

S. marcescens 1                                

Our partners• Physicians• Nurses• Lab• Infection Prevention• Patients

Physicians

• Earn respect-can take a long time to earn and a short time to lose!

• How do your physicians like to be contacted?oNotes, phone, cell phone, face to face

Nurses• Biggest allies• Also takes a long time to earn respect and

a short time to lose it!

oRN should shadow pharmacist and pharmacist should shadow RN

oBe persistent-will take time to turn things around

Lab

• Utilize the experts!• Educate regarding the antibiotics, organ

penetration etc• D zone inhibition• ESBL’s• FQ not for MRSA!

Patients

• You have to be able to interact with the patient

o Complianceo Costo Side effects

What we’ve tried that didn’t work

• IV to PO conversion by pharmacist

o 1 physician hold out stopped the processo 100% acceptance rate when we do suggest ito I’ve heard physicians say sometimes only way

to keep patient in the hospital is to be on iv antibiotics

Moving Towards…• Formalizing an Antimicrobial Stewardship committee• Physician champion• Review requirements for non critical access

hospitals to see where we could improve• Print a daily report from lab with culture results• Bring in a specialist to teach providers how to obtain

a proper culture sample• See if we can link up with an Infectious Disease

physician for consults• Help our IP RN more with identifying patients in LTCC

How to get started

• Identify and create your team• Identify your goals• Identify what you are already doing• Inform your facility of your plan• Create an antibiogram• Get a mentor-network• Russ Forney; list serves

Questions?

Karen Burk RPhClinical Pharmacy CoordinatorPowell Valley HealthcarePhone 307-754-1179kburk@pvhc.org

References

• Gauthier, T. & Unger, N [2013] Antimicrobial stewardship program: A review for the formulary decision-maker. Formulary Journal 48:7-17.

• Doron, S. & Davidson, L. 2011 Nov Antimicrobial Stewardship. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3203003/

• APIC Text of Infection Control and Epidemiology 3rd Ed 2009 Section V 62:9

• Ritter, Al, 2010 The 100/0 Principle. The Secret of Great Relationships