Professional Documents
Culture Documents
Objectives
Discuss and present aspects of hospital best
practice for antibiotic stewardship
Guidelines
Evidence for practice
M. tuberculosis
P. aeruginosa
H. pylori
Multi-Center (5 Hospitals)
Stewardship Intervention
5 academic medical centers in 2003-2004
6 month retrospective baseline, 6 month
intervention, and 6 month follow-up
2 nursing units at each facility
1,265 patients were enrolled in baseline, 1,163 in
the intervention, and 975 in the follow-up period
Used post prescription review and feedback
Summary
Much of the past 65 years represents failed
stewardship
Antimicrobial resistance is rapidly worsening
Need to develop successful programs
New programs must be based on practical ideas
well-founded in experimental data
B Spellberg. Arch Intern Med 2011;27:171(12):1080-1
Prospective Intervention
Program Study
Length and Periods of Usage
11-22
Months 35-44
Mixing
No Carbapenem
No Cephalosporin
No Pip/tazo
Months 23-34
Restriction
Pip/tazo
LOS
Cephalosporin
Multiple choices
Carbapenem
Therapy determined
by a patient-specific
strategy
23-34
Months 11-22
Prioritization
Months 1-10
Patient Specific
Changed in
consecutive patients
following a preestablished schedule
APCarbCipClin +
APCephP/T
* *
18
Carbapenem-resistant strains
16
ESBL-producing
Enterobacteriaceae
14
12
MRSA
10
* *
*
*
*
*
*
0
PS PP RP MP
Acinetobacter
baumannii
PS PP RP MP
PS PP RP MP
PS PP RP MP
Enterobacteriaceae
Pseudomonas
aeruginosa
Staphylococcus
aureus
PS PP RP MP
Enterococcus
faecalis
Patient Specific
By Schedule
Mixing
Mortality
17%
25%
10%
ICU LOS
22 Days
43 Days
26 Days
Vent Days
15
24
12
30-Day Vent
Free
23
17
21
Antibiotic Diversity
Program design
12-month period prior to establishment
of Department of Infection Control and
Prevention
6-month preparation period during which
some form of intervention occurred
18 months of Periodic Antimicrobial
Monitoring and Supervision (PAMS)
program divided into three 6-month
periods
Takesue Y, et al. J Hosp Infect. 2010;75:28-32.
40
P/T group
Quinolone
Meropenem Group
35
4GC Group
Others
% AUD
30
25
20
15
10
5
0
Mar 05-Feb 06 Preestablishment period
Relative antibiotic usage density (% AUD) is defined as the cumulative use in defined daily doses of 1
supervised class divided by the cumulative use of all 6 classes.
PAMS
40
35
30
% of resistant GNR/GNR
resistant
P. aeruginosa/GNR
%%
ofof
resistant
P. aeruginosa/GNR
% of MDR GNR/GNR
25
20
15
10
5
0
0.61
0.75
PAMS
0.78
0.81
0.86
0.83
2012
2013
0.91
0.89
Patient Specific
Practical Approaches to
Stewardship
React to a problem
Plan a comprehensive program
Usually ICU focus
Author
Agent
Reduction in
Ceph Use
Replacement
agent
Intervention
Successful?
1993
Meyer
CTZ
73%
I/C
Yes
1996
Rice
CTZ
50%
P/T
Yes
1998
Pea
3GC
87%
P/T
I/C
Yes
40 0% ESBLs
1998
Rahal
All Cephs
80%
I/C
Yes
1999
Landman
CTX
89%
A/S
Yes
CTZ
66%
P/T
CTZ
71% (Hosp. A)
P/T
Yes
2000
Patterson
27% (Hosp. B)
2003
Lan
3GC
96%
P/T
Yes
2004
Bantar
CTZ
94%
P/T
Yes
2007
Lee
3GC
45%
P/T
Yes
Planning
Stewardship Bundles
Bundles are useful in implementing a
multicomponent antibiotic use program
Components should not be dependent on one
another (e.g., want independent actions)
The components can be tracked as process
measures
- E. Dodds-Ashley. Session 68, paper 546. IDWeek2014,
Philadelphia, PA, USA. October 8-12, 2014
A Practical Approach to
the Antibiotic Care Bundle
Obtain proper cultures at infection onset
Use the fewest number of agents as initial therapy that will
treat the likely pathogens
1 broad-spectrum (monotherapy) agent replacing 2 or 3
antibiotics in combination exposes bacteria (normal flora) to 1/2 or
2/3 less antibiotic
Historical
(-lactam aminoglycoside)
Combination no benefit for sepsis
Paul M, et al. Cochrane Data Sys Rev 2009 (1) Art: CD003344.
Paul M, et al. Brit Med J (2004) doi:10.1136/bmj.38028.520995.63.
Combination Agents
Monotherapy
Community-acquired
pneumonia
Ceftriaxone + Azithromycin
Moxifloxacin
Complicated UTI
Ceftriaxone + Gentamicin
Ertapenem or Meropenem
Ertapenem + Vancomycin
Ceftaroline
or Tigecycline
Complicated Peritonitis
(hospital acquired)
Cefepime +
Metronidazole +
Vancomycin
Tigecycline
Complicated Peritonitis
(community acquired)
Levofloxacin +
Metronidazole
Piperacillin/ Tazobactam
Vancomycin + Rifampin
Linezolid
Neutropenic Fever
Ceftazidime + Amikacin
Piperacillin/ Tazobactam
Cefoperazone/Sulbactam
Outcome Measurement of
Antibiotic Bundle
Improve Outcome
Mortality
Discharge location
Re-admission
Improve Safety
Adverse events/Collateral damage
Reduce Resistance
Lower cost
Administration
Length of stay
Payer, Government
Drug cost
McGowan JE, ICHE 2012;33(4):331-337
Solomon DH, et al. Arch Int Med. 2001;161:1897-902.
Fraser GI, et al. Arch Int Med. 1997;157:1689-94.
Camins BC, et al. Infect Control Hosp Epidemiol. 2009;30:931-8.
Potential Benefits of a
De-escalation Strategy
A reduction in overall antimicrobial costs
Beneficial impacts on the antimicrobial
resistance profile of the institution
Decreased antibiotic-related adverse
events
- Superinfection with resistant bacteria
- Clostridium difficile
No alteration in treatment outcomes
Masterton RG. Crit Care Clin. 2011:27;149-162.
Potential Benefits of a
De-escalation Strategy: Recent Evidence
ICU-acquired pneumonia in 137
patients:
Safe when the patient is
clinically stable by day 5
(Days)
Weighted Antimicrobial
Choice Calculator
Nosocomial UTI (fictitious numbers)
Ampicillin/sulbactam Number/year % Susceptibility Number Susceptible
Bacteria in Disease
E. coli
350
0.65
227.5
K. pneumonia
24
0.54
12.96
P. aeruginosa
101
0.03
3.03
MSSA
21
1
21
MRSA
45
0
0
A. baumannii
2
0.45
0.9
S. marcescens
11
0.23
2.53
P. mirabilis
54
0.76
41.04
S. pyogenes
1
1
1
E. faecium
23
0.23
5.29
E. faecalis
114
1
114
B. fragilis
1
1
1
Total Number /year
750 % organisms captured =
% total activity of this agent =
99.6
57.59705489
Weighted Antimicrobial
Choice Calculator
Nosocomial UTI (fictitious numbers)
Piperacillin/tazobactam Number/year % Susceptibility Number Susceptible
Bacteria in Disease
350
0.98
343
E. coli
K. pneumonia
24
0.87
20.88
P. aeruginosa
101
0.95
95.95
21
1
21
MSSA
0
MRSA
45
0
A. baumannii
2
0.66
1.32
S. marcescens
11
0.96
10.56
P. mirabilis
54
0.97
52.38
S. pyogenes
1
1
1
E. faecium
23
0.23
5.29
E. faecalis
114
1
114
B. fragilis
1
1
1
Total Number /year
750 % organisms captured =
% total activity of this agent =
99.6
89.2075
Weighted Antimicrobial
Choice Calculator
Intraabdominal Infection
Ertapenem
Number/year % Susceptibility Number Susceptible
Bacteria in Disease
E. coli
92
1
92
K. pneumonia
44
1
44
P. aeruginosa
22
0
0
MSSA
7
1
7
0
0
MRSA
3
Aeromonas
3
0
0
Other
12
0.92
11.04
P. mirabilis
7
1
7
viridans streptococci
44
0.98
43.12
E. faecium
1
0
0
0
E. faecalis
3
0
Enterobacter
20
1
20
Total Number /year
750 % organisms captured =
% total activity of this agent =
34.4
86.88372093
Weighted Antimicrobial
Choice Calculator
Intraabdominal Infection
Number/year % Susceptibility Number Susceptible
Ertapenem
Bacteria in Disease
92
1
92
E. coli
1
44
K. pneumonia
44
0
0
P. aeruginosa
0
7
MSSA
7
1
0
3
0
MRSA
0
Aeromonas
3
0
11.04
Other
12
0.92
1
7
P. mirabilis
7
44
0.98
43.12
viridans streptococci
E. faecium
1
0
0
E. faecalis
3
0
0
Enterobacter
20
1
20
Total Number /year
750 % organisms captured =
% total activity of this agent =
31.46666667
94.98305085
What is Lacking?
Strategic
Operational
Support
Physician participation
Cooperation from colleagues
Network between hospitals and
regional bodies
Community center participation
Emphasis on diagnostic
procedures in guidelines
De-escalation
Education
Acknowledge effort
Provide information
Improve communication
Incorporate community
centers in the hospital
Antibiotic Stewardship
Programs
Emphasis on diagnosis
Incorporate de-escalation
as a tool
Formalize training in
antimicrobial use
Thank You!