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SIDP – Antimicrobial Stewardship Certificate Program Implementation of an Antimicrobial Stewardship Program: Justification, Cost, and Challenges
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Implementation of an Antimicrobial Stewardship Program: p g
Justification, Cost, and Challenges
Elizabeth D. Hermsen, Pharm.D., M.B.A., BCPS-IDDirector, Global Antimicrobial StewardshipDirector, Global Antimicrobial Stewardship
Merck elizabeth.hermsen@merck.com
The content presented here does not necessarily reflect the views of Merck.
Objectives
• List the resources necessary to initiate an ti i bi l t d hi (ASP)antimicrobial stewardship program (ASP).
• Identify potential financial and institutional barriers to implementation of an ASP.
• Justify the benefits of an ASP to administrative and clinical leadershipadministrative and clinical leadership.
SIDP – Antimicrobial Stewardship Certificate Program Implementation of an Antimicrobial Stewardship Program: Justification, Cost, and Challenges
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Outline
• BackgroundA ti i bi l t d hi• Antimicrobial stewardship– Introduction– Guidelines/strategy summary– Implementation– Subsequent justification– Best practices/Barriers
• Summary
Resistance AmongGram-Positive Organisms
Methicillin-resistant Staphylococcus aureus (MRSA)Vancomycin-Resistant Enterococci (VRE)Vancomycin-Resistant Enterococci (VRE)
60
50
40
30
20
Inci
denc
e (%
)
http://www.idsociety.org/uploadedFiles/IDSA/Policy_and_Advocacy/Current_Topics_and_Issues/Advancing_Product_Research_and_Development/Bad_Bugs_No_Drugs/Statements/AsAntibioticDiscoveryStagnatesAPublicHealthCrisisBrews.pdf. Accessed April 2013.
10
0
1980 1985 1990 1995 2000
SIDP – Antimicrobial Stewardship Certificate Program Implementation of an Antimicrobial Stewardship Program: Justification, Cost, and Challenges
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30
P/T TAZ IMP TOB CIP
Resistance AmongGram-Negative Organisms
4050607080
05
1015202530
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
K pneumoniae
010203040
1999 2000 2001 2002 2003 2004 2005 2007 2008
A baumannii*
*A baumannii not tested in 2006.Rhomberg PR, et al. Diagn Microbiol Infect Dis 2009;65:414-426.
Impact of Antibiotic Resistance
Joo (2011)
Micek (2012)
Rello (1997)
Kollef (1999)
Ruiz (2000)
Ibrahim (2000)
Dupont (2001)
Valles (2003)
Kumar (2009)
( )
Inappropriate initial therapy
Appropriate initial therapy
0 20 40 60 80 100
Luna (1997)
R e llo (1997)
Mortality (% )
Micek S, et al. BMC Infect Dis 2012;12:56. Joo EJ, et al. Infection 2011;39:309-318. Kumar A, et al. Chest 2009;136:1237-1248. Valles J, et al. Chest 2003;123:1615-1624. Dupont H, et al. Intensive Care Med 2001;27:355-362. Ibrahim EH, et al. Chest 2000;118:146-155. Ruiz M, et al. Am J Respir Crit Care Med 2000;162:119-125. Kollef MH, et al. Chest 1999;115:462-474. Rello J, et al. Am J Respir Crit Care Med1997;156:196-200. Luna CM, et al. Chest 1997;111:676-685.
SIDP – Antimicrobial Stewardship Certificate Program Implementation of an Antimicrobial Stewardship Program: Justification, Cost, and Challenges
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New Antibacterial Agents
United States, 1983-2012Ap
prov
als
161412108642
Boucher HW, et al. Clin Infect Dis. 2013;56: 1685-94.
01983-1987
1983-1987
1993-1997
1998-2003
2003-2007
2008-2012
• Antimicrobial-resistant organisms are prevalent and are increasingly
Key Points
prevalent and are increasingly encountered.
• Antibiotic resistance is bad for our patients and our healthcare system.
• Novel antimicrobial agents are sparse• Novel antimicrobial agents are sparse.
SIDP – Antimicrobial Stewardship Certificate Program Implementation of an Antimicrobial Stewardship Program: Justification, Cost, and Challenges
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Pattern of Antibiotic ResistanceDiscovery
Exuberant Use
Development of Resistance through Mutation and Natural SelectionMutation and Natural Selection
Rapid Dissemination via Clonal Expansion and Horizontal Transmission
Timeline of ResistanceFirst clinical use
Penicillin Ampicillin Cefotaxime
Imipenem(1985)
Fi t i t
Penicillin (1942)
Ampicillin (1962)
Cefotaxime (1979)
1940 2000
14Rice LB. Mayo Clin Proc 2012;87:198-208.
First resistanceOsteomyelitis
due to penicillinase-producing S aureus
(1949)
Description of TEM penicillinase
(1966) First clinical ESBL (SHV-2)
(1985)
Description of CTX-M(1990)
Carbapenemase from
Enterobacteriaceae(1993)
SIDP – Antimicrobial Stewardship Certificate Program Implementation of an Antimicrobial Stewardship Program: Justification, Cost, and Challenges
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0)Erythromycin resistance Erythromycin consumption
Controlling Erythromycin Resistance in Group A Streptococci, Finland
1.52
2.53
3.54
15
20
25
30
con
sum
ptio
n (D
DD
/100
0
ycin
resi
stan
ce (
%)
87 88 89 90 91 92 93 94 95 960
0.51
5
10
Year
Eryt
hrom
ycin
Eryt
hrom
y
97 98
Seppala,NEJM. 1997;337:441Post-study data courtesy of Ron Rolk, Pharm.D.
• Antimicrobial use is the key driver of antimicrobial resistance.
Key Points
antimicrobial resistance.
• More prudent use of antimicrobial agents can slow or reverse the development of resistance.
SIDP – Antimicrobial Stewardship Certificate Program Implementation of an Antimicrobial Stewardship Program: Justification, Cost, and Challenges
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Antimicrobial Stewardship
• A rational, systematic approach to the use of antimicrobial agents in order to achieve optimalantimicrobial agents in order to achieve optimal outcomes. Focus = patient and public health.
Correct agent
Right dose
Cure/prevent infection
Minimize toxicityRight dose
Appropriate duration
Minimize toxicity
Prevent emergence of resistance
Guidelines Summary• Acute care setting• Multidisciplinary involvement
A ltidi i li ASP t h ld i l d i f ti di (ID)– A multidisciplinary ASP team should include an infectious diseases (ID) physician and pharmacist and other key stakeholders as determined by the institution
– Policy statement ‒ physician-directed or supervised multidisciplinary ASP team with ≥ 1 member trained in antimicrobial stewardship
• Core strategies:– Prospective audit with intervention and feedback– Formulary restriction and authorization
• Supplemental strategies:
Dellit TH, et al. Clin Infect Dis 2007;44:159-177.
IDSA/SHEA/PIDS. Infect Control Hosp Epidemiol 2012;33:322-327.
– Education– Guidelines/
clinical pathways– Order forms
– De-escalation– Dose optimization– IV-to-oral conversion
SIDP – Antimicrobial Stewardship Certificate Program Implementation of an Antimicrobial Stewardship Program: Justification, Cost, and Challenges
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Prospective Audit with Intervention & Feedback
• Prescribing/dispensing occurs as usual• Targets established for potential intervention
– Examples:• Drug-bug mismatch• Redundant therapy• Poly-antibacterial therapy
• Retrospective review & intervention if needed• Retrospective review & intervention if needed– Start/stop/change therapy– De-escalation– Dosing optimization
SIDP – Antimicrobial Stewardship Certificate Program Implementation of an Antimicrobial Stewardship Program: Justification, Cost, and Challenges
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Prospective Audit & Feedback
• Advantages– Maintain prescriber
• Disadvantages– Compliance voluntary– Maintain prescriber
autonomy
– Educational opportunity
– Review patient information before interaction
– May decrease inappropriate antimicrobial use
– Compliance voluntary
– Identification of patients may require computer support
– Reluctance to change therapy if the patient is doing well
– Permits some inappropriate antimicrobial use (withantimicrobial use (with retrospective audit)
– May be difficult to identify decision-making team
Formulary Restriction & Preauthorization
• Restricted antimicrobial formulary developed with fcriteria to define appropriate use
– Example: micafungin• Invasive aspergillosis in a patient failing/intolerant of
therapy with voriconazole.
• Empiric treatment of moderate-severe invasive candidiasis or those with recent azole exposure.
• Candidal infections refractory to azoles.
• Invasive candidiasis due to non-albicans species.
• Authorization prior to dispensing
• Selective susceptibility reporting
SIDP – Antimicrobial Stewardship Certificate Program Implementation of an Antimicrobial Stewardship Program: Justification, Cost, and Challenges
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Formulary Restriction & Preauthorization
• Advantages • Disadvantages– Direct control over
antimicrobial use
– Effective control of antimicrobial use during outbreaks
– Decreased inappropriate f ti i bi l
– Personnel needs
– Antagonistic relationship (loss of autonomy)
– Therapy may be delayed
– Manipulation of the system
use of antimicrobials – ID physicians often exempt
– “Squeezing the balloon”
Education
• Essential foundation of every ASP
• Large group/general vs. one-on-one/patient-specific
• Attempt to change behavior throughAttempt to change behavior through acquisition of new knowledge or reminder of existing knowledge
SIDP – Antimicrobial Stewardship Certificate Program Implementation of an Antimicrobial Stewardship Program: Justification, Cost, and Challenges
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Bacterial resistance • Extent, causes, and spread
• Mechanism of action, toxicity, and costs
Core Principles for Education
Mechanism of action, toxicity, and costs (collateral damage)
• Infection, isolation and identification of bacteria,susceptibility to antibiotics
Antibiotics
Diagnosis of infection
Treatment of infection
Infection prevention
• Indication for antimicrobials
• Antibiotic prophylaxis
Medical records
Antibiotic prescribing
• Recording and documentation of antimicrobial choice, duration, and timing
• Empiric therapy, communication with microbiology laboratory, following guidelines in clinical practice
Communication skills • Discussion technique
Pulcini C, Gyssens IC. Virulence 2013;4:192-202.
Education
• AdvantagesI f
• DisadvantagesP i– Increase awareness of
guidelines, susceptibility patterns
– May influence prescribing behavior
– Promotes acceptance
– Passive
– Time consuming
– Attendance often mandatory
– Dilution
of ASP
SIDP – Antimicrobial Stewardship Certificate Program Implementation of an Antimicrobial Stewardship Program: Justification, Cost, and Challenges
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Guidelines/Clinical Pathways
• Create protocols to guide antimicrobial use f i i f tifor a given infection– Specific to institutional formulary, patient
populations, and resistance patterns
• Evidence-based
Guidelines/Clinical Pathways
• AdvantagesD i i
• DisadvantagesAdh i ll– Decrease inappropriate
antimicrobial use
– Form of education
– Adherence is usually voluntary
– “Cookbook medicine”
– Maintenance
– Awareness
SIDP – Antimicrobial Stewardship Certificate Program Implementation of an Antimicrobial Stewardship Program: Justification, Cost, and Challenges
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Antimicrobial Order Forms
• Paper vs. integrated into electronic health drecord
– Optional vs. mandatory
• Potential Uses:– Support guidelines/pathways
– Communicate/enforce ASP recommendations– Communicate/enforce ASP recommendations
– Enhance documentation & thought process
Example: Surgical Prophylaxis• Features of Form
– Antibiotic recommendations with alternatives for allergiesallergies
– Dosing automatically adjusted by pharmacists for weight and renal function
– Automatic antibiotic discontinuation at 24 hours– Flexibility for “off-protocol” prescribing
– Pre-/post-intervention study (n=406; n=396, respectively)espec e y)– Significantly increased appropriate antibiotic choice
(62% vs. 85%, p<0.001), dose (62% vs. 90%, p<0.001), and duration (78% vs. 89%, p<0.001) and decreased cost ($46 vs. $40, p=0.02)
Hermsen ED, et al. Infect Control Hosp Epidemiol. 2008;29:457-61.
SIDP – Antimicrobial Stewardship Certificate Program Implementation of an Antimicrobial Stewardship Program: Justification, Cost, and Challenges
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Order Forms
• Advantages • DisadvantagesA il bili– Increase compliance
with guidelines/ pathways
– Form of education
– Enhance documentation
– Availability
– “Cookbook medicine”
– Maintenance
– Potential for therapy to be inadvertently stoppeddocumentation
– Decrease inappropriate use
pp
De-Escalation
• Narrow spectrum of activity as appropriate in response to culture/susceptibility results andresponse to culture/susceptibility results and clinical response
SIDP – Antimicrobial Stewardship Certificate Program Implementation of an Antimicrobial Stewardship Program: Justification, Cost, and Challenges
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De-escalation Case
• EB, a 61 y.o. female, was admitted to the hospital on 12/26 with abdominal pain, brown p p ,vomit, fever, and chills.– Started on piperacillin/tazobactam and metronidazole
• Underwent appendectomy and abscess drainage on 12/30– Culture Bacteroides spp.
I d O i t th t t• Increased O2 requirements over the next two days. Chest X-ray – LLL consolidation– Added ciprofloxacin and vancomycin– Sputum culture – K. pneumoniae and C. albicans– Added fluconazole
De-escalation Case
ASP ASP
Date 26 27 28 29 30 31 1 2 3 4 5 6 7
PTZ
MTZ
CIP
VA
FLUC
SIDP – Antimicrobial Stewardship Certificate Program Implementation of an Antimicrobial Stewardship Program: Justification, Cost, and Challenges
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De-escalation• Advantages
– Balance need for initial
• Disadvantages– Reluctance to change
fuse of broad-spectrum therapy to “get it right up front” with need to target the organism
– May influence future prescribing behavior
therapy if patient is doing well
– May narrow therapy inappropriately
– Decrease inappropriate use
Dose Optimization
• Use pharmacokinetic (PK)/pharmacodynamic(PD) principles to choose dose that will most(PD) principles to choose dose that will most likely eradicate the organism, minimize toxicity, and prevent resistance
• Affected by minimum inhibitory concentration (MIC)
• Examples:– Once-daily dosing of aminoglycosides
– Extended infusion β-lactams
SIDP – Antimicrobial Stewardship Certificate Program Implementation of an Antimicrobial Stewardship Program: Justification, Cost, and Challenges
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Impact of MIC value on PD TargetsBeta-lactam via standard 30-minute infusion
Breakpoint for susceptibility = 4 mg/L.
cent
ratio
n (m
g/L)
~30% T>MIC
Isolate #2MIC 2 mg/L
~50% T>MIC
Both isolates are susceptible, but isolate #2 has a higher MIC & therefore less T>MIC when administered the same dose.
2
Time (hrs)
Con
c
1 2 3 4 5
MIC 2 mg/L
Isolate #1MIC 1 mg/L
6
1
Slide adapted from presentation by Daryl DePestel, Pharm.D., BCPS-ID.
Piperacillin/tazobactam Target Attainment vs. P. aeruginosa
3.375g q8h over 4h achieves over 90% probability of target attainment up to an MIC of 16 mg/L versus an MIC of 1 mg/L for standard dose of 3.375g q6h over 30min
Lodise TP, et al. Clin Infect Dis. 2007;44:357-363.
SIDP – Antimicrobial Stewardship Certificate Program Implementation of an Antimicrobial Stewardship Program: Justification, Cost, and Challenges
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Dose Optimization
• AdvantagesI lik lih d f
• DisadvantagesL i i– Increase likelihood of
achieving PD target
– May decrease resistance
– May decrease drug costs
– Logistics
– Lack of MIC data
– May increase pharmacy/nursing time
– Potential for error
– May allow use of drug for organisms with increased MICs
How to Start
SIDP – Antimicrobial Stewardship Certificate Program Implementation of an Antimicrobial Stewardship Program: Justification, Cost, and Challenges
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Steps Toward Building an ASP
Identify Key StakeholdersStakeholders
Build Buy-In
How do you gain support?
FQ-resistant E. coli MDR P. aeruginosa50
25
e
05
101520253035404550
Per
cent
Res
ista
nce
0
5
10
15
20
Per
cent
Res
ista
nce
NHSN 2007-2008
NHSN 2009-2010
Your hospital 2007-2008
Your hospital 2009-2010
Sievert DM, et al. Infect Control Hosp Epidemiol. 2013;34:1-14.
SIDP – Antimicrobial Stewardship Certificate Program Implementation of an Antimicrobial Stewardship Program: Justification, Cost, and Challenges
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National Hot Topic
• CDC NHSN AUR ModuleCDC 7 C El t f H it l A ti i bi l• CDC: 7 Core Elements of Hospital Antimicrobial Stewardship Programs
• PCAST Report, National Strategy, Executive Order, & National Action Plan to Combat Antibiotic-resistant BacteriaCMS Proposed Rule(s)• CMS Proposed Rule(s)
http://www.cdc.gov/nhsn/PDFs/pscManual/11pscAURcurrent.pdf. Accessed August 2014.
http://www.cdc.gov/getsmart/healthcare/pdfs/core-elements.pdf. Accessed August 2014.
Pollack LA et al. Clin Infect Dis. 2014;59(S3):S97–100.
http://www.whitehouse.gov/sites/default/files/microsites/ostp/PCAST/pcast_carb_report_sept2014.pdf. Accessed November 17, 2014.
http://www.whitehouse.gov/sites/default/files/docs/carb_national_strategy.pdf. Accessed November 17, 2014.
http://www.whitehouse.gov/the-press-office/2014/09/18/executive-order-combating-antibiotic-resistant-bacteria. Accessed November 17, 2014.
https://www.whitehouse.gov/sites/default/files/docs/national_action_plan_for_combating_antibotic-resistant_bacteria.pdf
https://s3.amazonaws.com/public-inspection.federalregister.gov/2015-17207.pdf
Steps Toward Building an ASPIdentify Key
Stakeholders
Build Buy-In
Identify Core/Supplemental
Strategies
Delineate Goals & Outcome Measures
SIDP – Antimicrobial Stewardship Certificate Program Implementation of an Antimicrobial Stewardship Program: Justification, Cost, and Challenges
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Outcome Measures
Patientoutcomes
Collateraldamage
Drug consumption/
Processmeasuresoutcomes
• Clinical cure• LOS/ICU LOS• Readmission• Patient mortality
damage
• Selection of pathogenic organisms (e.g., CDI)
• Resistance• Toxicity
consumption/ costs
• Defined daily doses, days of therapy, length of therapy
• Predefined costs, prices, or charges
measures
• Appropriateness of therapy
• Adherence to guidelines
• Time to appropriate therapy
McGowan JE. Infect Control Hosp Epidemiol 2012;33:331-337. Goldmann DA, et al. JAMA 1996;275:234-240.
Steps Toward Building an ASPIdentify Key
Stakeholders
Build Buy-In
Identify Core/Supplemental
Strategies
Delineate Goals & Outcome Measures
Draft Formal Proposal
SIDP – Antimicrobial Stewardship Certificate Program Implementation of an Antimicrobial Stewardship Program: Justification, Cost, and Challenges
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Formal Proposal
• Background– Impact of resistanceImpact of resistance
– ASP literature
– Legislative/policy proposals/changes
• Proposed Program– Goals
– Required core personnel & compensation
– Core/supplemental strategies
• Benefits & Outcome Measures– Focus on more appropriate patient care… then reduced costs
– Period of review
• Future plans & Areas of Growth
• Financial Justification
Initial Cost Justification
• Personnel
• Cost savings vs. Cost avoidance
• Length of stay
SIDP – Antimicrobial Stewardship Certificate Program Implementation of an Antimicrobial Stewardship Program: Justification, Cost, and Challenges
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ASP is approved! Now what?
Recruitment…
SIDP – Antimicrobial Stewardship Certificate Program Implementation of an Antimicrobial Stewardship Program: Justification, Cost, and Challenges
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Implementation Plan: Key Considerations
• Low hanging fruit
• Data availability
• Core strategy– “Hours of operation”
– Coverage in the absence of ASP personnel
• Mechanism of communication
• Prescriptive authorityp y
• Intervention documentation/tracking
• Trending/benchmarking
• Reporting structure and frequency
• Integration across multiple institutions
Building Buy-In
• Identify key opinion leadersI di id l ti– Individual meetings
• Marketing– Branding
– Elevator pitch
Ne sletters/”La nch”– Newsletters/”Launch”
• Communication/Education
SIDP – Antimicrobial Stewardship Certificate Program Implementation of an Antimicrobial Stewardship Program: Justification, Cost, and Challenges
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Committee Infrastructure
• Antimicrobial Subcommittee
• Pharmacy & Therapeutics Committee
• Medical Executive Committee
• Clinical Microbiology Operations CommitteeCommittee
• Infection Prevention Committee
• Quality/Patient Safety Committee
Subsequent Cost Justification
($)
obia
l Exp
endi
ture
s
ASP
Ant
imic
ro
Time (yrs.)
SIDP – Antimicrobial Stewardship Certificate Program Implementation of an Antimicrobial Stewardship Program: Justification, Cost, and Challenges
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Subsequent Cost Justification (cont.)
• Specific projectsED Contaminated Blood Cultures Oct 2006-May 2008
5
6
7
8
9
10
t con
tam
inate
d
lab draw
nurse drawTotal
Trend
0
1
2
3
4
Oct-06
Nov-06
Dec-06
Jan-07
Feb-07
Mar-07
Apr-07
May-07
Jun-07
Jul-07
Aug-07
Sep-07
Oct-07
Nov-07
Dec-07
Jan-08
Feb-08
Mar-08
Apr-08
May-08
Perc
ent
ED = emergency department
Subsequent Cost Justification (cont.)
• Specific projects
– Blood culture contamination in ED• 7.4% in Oct 06 to 2.1% in May 08
• ~4800 blood cultures/year
• Previous study contaminated culture costs $104.75
• Saved ~$26,500
SIDP – Antimicrobial Stewardship Certificate Program Implementation of an Antimicrobial Stewardship Program: Justification, Cost, and Challenges
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• Antimicrobial surgical prophylaxis order f
Subsequent Cost Justification (cont.)
form
– Pre-/post-intervention study
– Average cost of antimicrobial surgical prophylaxis decreased by $6/patient (p=0.02)
70% compliance with form– 70% compliance with form
– Save ~$30,000/year
Hermsen ED, et al. Infect Control Hosp Epidemiol 2008;29:457-61.
• Clostridium difficile infection (CDI)management
Subsequent Cost Justification (cont.)
management
– 2001 to 2007 CDI rate increased from 0.99 to 1.46 cases/1000 patient days
– Management algorithm and cleaning procedures implemented July 2007p p y
• ASP, Infection Control, Microbiology, Environmental Services, ID, Gastroenterology, Hem/Onc, Solid Organ Transplantation, and Pediatrics
SIDP – Antimicrobial Stewardship Certificate Program Implementation of an Antimicrobial Stewardship Program: Justification, Cost, and Challenges
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Clostridium difficile Infection Rates
2.5
Subsequent Cost Justification (cont.)
0.94
2
1.62
1.73
1.84
1.36
1.92
1.51
0.990.9
1.04
1.17
1.44
1.281.36
0.95
1.29
1.031
1.5
2
ate
per 1
000
patie
nt d
ays
0.76
0.68
0
0.5
Jan-07
Feb Mar Apr May Jun July Aug Sept Oct Nov Dec Jan-08
Feb Mar Apr May June July Aug
Month
Ra
• Clostridium difficile infection (CDI)management
Subsequent Cost Justification (cont.)
management
– From Jul 2007-Aug 2008, decreased CDI rate by 1.21 cases/1000 patient days 194 cases/year
– $2 454 attributable costs/CDI episode*$2,454 attributable costs/CDI episode saved ~$475,000
*Dubberke ER, et al. Clin Infect Dis 2008;46:497-504.
SIDP – Antimicrobial Stewardship Certificate Program Implementation of an Antimicrobial Stewardship Program: Justification, Cost, and Challenges
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Tips for Success• Round with ID team, study antibiogram trends, and
meet with key stakeholders to survey for ID problemsp
• Network!• Marketing• Information resource (website)• Build relationships across disciplines• Standard operating procedures, policies• Ensure appropriate data and timing• Establish mechanism for evaluation• Establish mechanism for evaluation• Study what you do• Partner with Finance Dept.• Budget for growth• Baby steps
Potential Barriers• Enhancing patient care vs. saving money• Human and financial resources• Information systems• Communication• Inflation/new products• Evaluation• ID staff resistanceID staff resistance• Internal medical staff resistance
– Enforcement
• Competing initiatives
SIDP – Antimicrobial Stewardship Certificate Program Implementation of an Antimicrobial Stewardship Program: Justification, Cost, and Challenges
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Summary
• Antimicrobial resistance is increasing negatively affects patients & healthcare g y psystems
• More prudent use of antimicrobial agents can slow or reverse the development of resistance antimicrobial stewardship– Focus is patient outcomes and public health
• Many potential best practices and barriers learn by sharing experiences!
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