The New War on Bugs: Crafting an Effective Antibiotic Stewardship Program More than half of all hospital patients are treated with antibiotics and prescribing practices vary widely, even within hospitals. Efforts to rationalize antibiotic use have been stymied by delays in obtaining specific diagnoses, by the volume of prescriptions written each day and by the difficulty of extracting meaningful data from scattered clinical, laboratory and pharmacy records. But the push is on – from the White House, the CDC, infectious disease specialists, the industry – for more judicious use of antibiotics through antibiotic stewardship programs. Hear how leading health care institutions have moved from education to active surveillance to intervention, reducing infections and lowering costs.

1. On the Front Lines of
Antimicrobial Stewardship
Marci Drees, MD, MS, FACP
Hospital Epidemiologist
Hospital of Tomorrow Summit
19. October 2015
Disclosures: None to report.

2. Dela-where?

3. Setting
 Two-hospital, 1100-bed private not-for-profit
community-based academic health care system
 >50,000 admissions, 185,000 emergency visits annually
 21st in U.S. for admissions and ED visits
 Level 1 trauma, level 3 NICU
 > 11,000 employees
 ~1600 Medical-Dental staff (400 employed)
 Largest teaching affiliate of Sidney Kimmel Medical
College at Thomas Jefferson University
 ~450 employed or rotating residents/fellows (No ID)
 ~12,000 rotating students annually

4. Evolution of Stewardship at CCHS
 Pre-2009: 1 ID-trained PharmD, working with 1
private ID physician
 ~2009-10: different ID-trained PharmD hired,
stewardship “committee” formed
 2011: current ID-trained PharmD hired
 2013: 2nd ID-trained PharmD hired
 2014: Revamped ASP committee launched
 Co-chaired by ID PharmD and private ID physician
 3rd ID-trained PharmD hired (left after 6 mo.)
 2015: replacement 3rd PharmD hired

5. Early Accomplishments
 Series of guidelines developed for front-line staff
 Pneumonia, skin/soft tissue infections, sepsis, UTI
 Duration of therapy
 Vancomycin dosing by pharmacy protocol
 Procalcitonin guidelines
 Working with microbiology lab to adopt and
implement Verigene® as a stewardship tool
 Identification of blood culture organism within hours

6. Discussion Points
 Engagement
 “Culture/testing stewardship”
 Clinical Decision Support
 Metrics

7. Engagement
 ASP committee revamped early 2014
 Co-chaired by David Cohen, MD
 Private practice (inpt/outpt)
 Chair of ID Division
 Force of personality
 Membership expanded
 Pharmacy, ID docs, microbiology, infection prevention
 Hospitalists, residents, surgery PAs, students, ED, family
practitioners, critical care PAs
 Strong educational/outreach component
 “Staphylococcupalooza”

8. Culture/Testing Stewardship
 Recognition that positive
cultures/tests very difficult
NOT to treat
 C. difficile colonization
 Asymptomatic bacteruria
 Interventions
 Laxative alert
 Previous C. difficile alert
 Future:
 Urinalysis with reflex to urine
culture
 Requirement for symptom
documentation when
ordering urine cultures

9. Culture/Testing Stewardship
 Recognition that positive
cultures/tests very difficult
NOT to treat
 C. difficile colonization
 Asymptomatic bacteruria
 Interventions
 Laxative alert
 Previous C. difficile alert
 Future:
 Urinalysis with reflex to urine
culture
 Requirement for symptom
documentation when
ordering urine cultures

10. Clinical Decision Support
 “Forcing function”
 Or, making the right thing to do the EASIEST thing
to do
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11. Clinical Decision Support
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12. Clinical Decision Support
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13. Metrics
 Intra-facility
 Internal benchmarking for
targeted antibiotics
 Evaluate effect of
interventions
 Compare antibiotic use
between similar units
 Compare individual providers
 Inter-facility
 Benchmarking to similar
institutions
 What is the “right” amount
of antibiotic use?
 Possible metrics
 Resistance rates:
 Annual antibiogram
 Pharmacy interventions
 ASP pharmacist
 Unit-based pharmacists
 Utilization (DOT)
 Safety Surveillor® (Premier)
 Power Insight (Cerner®)
 University Health System
Consortium (UHC)
 Outcomes (?)

14. Measuring Utilization
 Data mining program (SafetySurveillor®)
 Pro: pulls in micro and pharmacy data (bug/drug mismatch)
 Con: orders, not actual administration; labor intensive
 SAP Business Objects software (Power Insight)
 Pro: anything in PowerChart available for query (barcode)
 Con: labor-intensive, slow
 UHC
 Pro: ability to benchmark nationally to similar institutions
 Con: based on charges; 3-month delay
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15. Utilization Data (UHC)

16. External Benchmarking (UHC)

17. On the Front Lines…
 Engagement is key…
 Private ID docs
 Employed and private hospitalists
 Many, many others who prescribe antibiotics
(or obtain the tests that prompt antibiotics)
 Measurement is hard…
 Interventions should make less work, not more, for
frontline providers.

18. Acknowledgments
 Nicole Harrington, PharmD
 David Cohen, MD
 Jennifer Lukaszewicz, PharmD
 Julianne Gardner, PharmD
 Donna Walsh, PharmD
 Kim Taylor, BSN, RN
 Sharon Kleban, MA
 Steve Eppes, MD
 Paul Sierzenski, MD, MS-HQS