Antimicrobial Stewardship A Global Solution!

1. This presentation was presented at
Apollo International Forum on
Infection Control (AIFIC’ 2013),
Chennai
The presentation is solely meant for
Academic purpose

2. Antimicrobial Stewardship
Different Challenges need Different Solutions

3. Columbus, Ohio USA

4. The Ohio State University Medical Center
• James Cancer Center 165 beds
bone marrow transplants & oncology
• Ross Heart Hospital 130 beds
Heart and lung transplants
• The Ohio State University Hospital 850 beds
solid organ transplant, General Medicine
Surgery, SICU, MICU, NICU, Burn unit

5. Antimicrobial Resistance: A Global Problem
Antimicrobial Stewardship: A Global Solution!
MDRO are a plane ride away!
Examples: NDM-1,KPC, ESBL, Tuberculosis

6. Antimicrobial Stewardship
A Global Solution!

7. Why Stewardship?
 HAI’s: significant morbidity, mortality and costs
 100,000 deaths annually
 $4.5 to 5.7 billion patient care cost
 Transmission occurs most often via contaminated
hands of HCW
 Negative publicity for the hospital (patient safety issue)
The Ohio State Football Stadium holds 105,000 people

8. Stewardship: A team approach

9. Challenges and Barriers in India
• Lack of ID trained physicians and
pharmacists
• Lack of funding
• Open access to antibiotics
• Generics

10. What are USA patient’s reading?
Ref: Wall Street Journal January 2013

11. What works What Doesn’t
Social competence Socially challenged
Do you enjoy interacting with others? Prefer to work alone
Needs to be liked by everyone
Avoids conflict at all costs
Technical competence Technically challenged
Are you an ID expert?
Hopes others on the team will do the work
Can you lead a team?

12. What Works What Doesn’t Work
Excited to change Frustrated at the thought of change
Implementation of ASP should be conceived as a
process of cultural and system change for the hospital
If the team does not possess the change management
competence, it may be necessary to involve external
experts

13. Organizational Capacity for Change
• Trustworthy leadership
Do MDs know/trust the steward?
• Capable Champions
Are efforts led by people with interpersonal
communication and leadership skills?
• Accountability
Does ASP have a clearly defined role and
responsibility? Are there consequences for non-
compliance?
• Involved Management
Do they support the program and connect with
leadership? Judge WQ et al. Journal of Business Research. 2005;58:893-901.

14. What works: Define the Stewardship activities
What activity will be performed… Examples
IV to PO
Kinetic dosing of antibiotics
Authorization of restricted antibiotics
Feedback for targeted antibiotics
By what personnel…. Dedicated pharmacist
Physician
Residents or students
With what frequency… Mon-Friday
7 days a week
24/7
With what authority… Protocols for IV to PO
Kinetic dosing protocol
Communication of recommendation via
chart

15. What works?
Pick the low hanging fruit
IV to PO conversion
Double anaerobic therapy
Broad spectrum antibiotics > 3 day and proton pump inhibitors
(increase risk of C. difficile)
Vancomycin > 3 days and no MRSA
Positive blood culture and no antibiotics
Thrombocytopenia and linezolid
Ref: Goff DA. et al . Clin Inf Dis 2012 55(4):587-92

16. Insist on Infection Prevention Strategies
• Provide education to patients and
family members
• Provide/post medical staff
scorecards with frequency and
trends of MDRO
Do physicians know the top 5 organisms in their hospitals?
• Do physicians know the rate of ESBLs, C difficile, MRSA?

17. Challenge
How can stewardship
control the spread of
MDRO in your hospital?

18. (X Represents VRE Culture Positive Sites AFTER Cleaning)
Hayden M, The Risk of Hand and Glove Contamination after Contact with a
VRE (+) Patient Environment. ICAAC, 2001, Chicago, IL.

19. USA and India working together to
improve hand hygiene
• Method: 17 bed ICU used remote video
auditing with feedback
• Auditors in India viewed live video of HCW
in a US hospital performing hand hygiene
• Each observation was assigned pass/fail
Ref: Armellino D et al. 2012 Clin Inf Dis 54(1) 1-7.

20. Results
60,542 observations
• Pre-feedback hand hygiene rates
6.5% (3.5%-9.8%) by remote 24/7 observation
• Post-feedback
30.8% the first few weeks
87.9% with light-emitting diode boards

21. Message Posted on LED boards

22. Black Light Marker
• Fluorescent marker
– An invisible gel that glows under blacklight
– Applied to surfaces in over 40 US hospitals
– An inert, safe, and unreactive substance
Without black light
Ref: Carling PC. Clin Infect Dis 2006;42(3):385

23. Challenge
How can you control the spread of MDRO in your hospital?
Solutions
1. Novel technology
2. Empower patients*
(only 14% of patients feel comfortable asking their MD/RN to wash their hands)
Ref *2012 ICHE Ottum 33(12)1282-4,
3. Identify patient s at high risk for MDRO
Ref: Han et al. 2012 ICHE;33(12) 1242-5
4. Chlorhexidine bathing
70% decline in CDI with daily bathing
Ref: Rupp et al. 2012 ICHE;33(11):1094-1100

24. Stewardship in Limited
Resource Hospitals around
the world

25. Stewardship in S. Africa
Challenges: 3 ID physicians for all of S Africa, lack of funding,
pharmacist are not ID trained, some public hospitals do not have sinks

26. Stewardship and S. Africa
• Implemented Feb 2012
• Dedicated “champions” across S.
Africa (physicians, infection control practitioners,
pharmacists, microbiologists)
• Collaboration between public and
private hospitals, administration and
government

27. Stewardship and S. Africa
• Projects
iv to oral
de-escalation
implementing antibiograms
• Education
12 enrolled in on-line certification program in US
• email communication
• Conference calls, Facetime, Skype
• Integrate “apps” to educate providers
• Twitter

28. Outcomes of Stewardship
• S. Africa
successful conversion of IV to PO
therapeutic vancomycin levels
develop antibiogram
• Dubai
ICU improve “Hang-time” of antimicrobials
• Serbia
developed a “team” to identify how to utilize
micro data to guide empiric use of antibiotics

29. Antimicrobial Stewardship Management of
Infections : Beyond the Costs of Antimicrobials
Ref: Goff D. et al. Inf Dis Special Ed. 2012 15:35-46

30. Antimicrobial Stewardship Management of
Infections : Beyond the Costs of Antimicrobials
Ref: Goff D. et al. Inf Dis Special Ed. 2012 15:35-46

31. Challenge
How does stewardship
impact patient care?

32. Clinical Outcome Measures
Can you show improvement in clinical outcomes?
• Reduced LOS
Bauer K., Goff D. Clin Inf Dis 2010; 51(9):1074–1080
Fishman N. Am J Med 2006;119 (6 suppl 1) S53-S61
Gentry CA AM J Health Syst Pharm 2000;57(3) 268-74.
• Better patient outcome
Bauer K., Goff D. Clin Inf Dis 2010; 51(9):1074–1080
Fishman N. Am J Med 2006;119 (6 suppl 1) S53-S61
White A. et al Clin Inf Dis 1997;25:230-9.
• Decreased inappropriate use
Gandhi T. Crit Care Med 2010;38(8 suppl) S315-323
Apisarnthanarak A. Clin Inf Dis 2006;42(6) 768-775

33. What works: Technology and Education
• ASP certification program in USA
MAD-ID Making a Difference Infectious Diseases international online program
S. Africa, Singapore, Canada, Saudi Arabia, Australia
http://mad-id.org
• Free apps from the Apple store
Idpodcasts Weekly podcasts on ID topics
• Free webinars and handouts
ASHP American Society of Health Systems Pharmacists
www.LeadStewardship.org
• http://www.cdc.gov/getsmart/specific-groups/hcp/index.html
free handouts, brochures, powerpoint slides on ASP

34. So what can you do?
• Start now
• Collaborate
• Identify key leaders to develop guidelines
(based on national guidelines, tailored to your institution)
• Consequences for non compliance?
• Educate (telemedicine programs) School of Telemedicine and
• Biomedical Informatics, Sanjay Gandhi Postgraduate Institute of Medical Sciences
Lucknow, India.
• Patient’s lives depend on effective stewardship

35. Stewardship