190 likes | 444 Views
Flushing Hospital Medical Center. Antimicrobial Stewardship Program Presented by: Judith Fine, MSc, MPH, M(ASCP); Director of Infection Control. Rehana Jamali, PharmD Medication Safety Officer Flushing Hospital Medical Center. Flushing Hospital.
E N D
Flushing Hospital Medical Center Antimicrobial Stewardship Program Presented by: Judith Fine, MSc, MPH, M(ASCP); Director of Infection Control Rehana Jamali, PharmD Medication Safety Officer Flushing Hospital Medical Center
Flushing Hospital • Local Community Hospital incorporated since 1884. • Certificate of Occupancy: • Med Surg beds • ICU beds; Medical/ Coronary/ Surgical/ NICU. • Percentage of Medicare/ Medicaid NH patients 70-80% • Scope of services rendered: • Pediatrics, Maternal Child, Level III NICU, Med/ Surg, Geriatrics, Continuum of Care; TCU, Hospice. • High Bioburden- community onset ( NH) MDRO incidence • High Foreign born patient population.
Antimicrobial Stewardship Committee Members • ANTIMICROBIAL STEWARDSHIP COMMITTEE • Deborah Asnis, MD, Chairperson, Director Infectious Disease • Peter Barra, MD, Medical Director, Administration • Zeinab El Boghdadly, MD, Resident PGY3, Medicine • Roseann Ciuffo, MD, Physician, Infectious Disease • Robert Crupi, MD, Chairman, Emergency Room • Raffaela Dellino, R.Ph., Supervisor, Pharmacy • Jaime Devera, RN, Assistant Director, Nursing • Esra Fakioglu, MD, Pediatric, Infectious Disease • Catherine Ferrari, RN, Administrator, Administration • Judith Fine, MSc, MPH, M(ASCP) Director, Infection Control • Minerva Garcia, Supervisor, Microbiology • Tae Hahn, R.Ph, MS, Pharm D, Assistant Director, Pharmacy • Rehana Jamali, Pharm D, Medication Saftey Officer, Medisys Informatics • Alexander Kintzoglou, MD, Chairman, Medicine, Dept. of Medicine • Kelly McGuire, RD, CDN, Clinical Dietitian, Nutrition • Siamack Nemazie, Cheif Medical Informatics Officer, Medisys Informatics • Martha Niederland, MD, Chairwoman, Pathology • Ruben Silvestre, RN, Director, Nursing Administration • Iqbal Tak, Physician, Infectious Disease
AST Program • Aim to promote rational antimicrobial prescribing with the goal of reducing the incidence of Multi-Drug Resistant Organisms (MDROs) infections • Correlation between antibiotic prescribing patterns and antibiotic resistance • Optimize the selection, dose, duration, and route of therapy with the most appropriate drug for the patient’s condition • Recommendations: use an alternative therapy, de-escalate to an oral alternative, or to use no therapy, when necessary
AST Program • Strategies: • Antibiogram published annually – local antibiotic susceptibility data, selection of empirical antibiotic therapy only • Monitor restricted antibiotics – initial orders, dosing, duration, de-escalation based on C&S results or discontinuation, dose adjustments based on renal function • Guidelines • Renal function assessment – creatinine clearance calculation • Clostridium Difficile Infection management • Antibiotic Order Sets • Education • Outcomes • Reduction in Adverse Drug Events • Antimicrobial Resistance • Reduce Length of Stay – IV to PO conversion program • Cost containment
Antimicrobial Stewardship Program Gap Analysis • Antimicrobial Use Data • Microbiology DataAdministration/Informatics/Medical Staff • Stewardship Strategies • Data collection • Best Practices • Determine Defined daily dose calculation for certain antibiotic and report it on a monthly basis Look for trends on a monthly basis for any significant variances in units purchased and dollars spent
Antimicrobial Stewardship Program Gap Analysis • IV to PO Conversion Program • Antibiotic Restrictions • Renal dosing adjustments
Empiric Antimicrobial guidelinesDiagnosis driven/ clinical syndromes • CAP( Community Acquired Pneumonia ) • HCAP (Health care associated Pneumonia) • Complicated Skin and Skin Structure Infection • ComplicCNS infection (meningitis/Encephalitis)ated Urinary Tract Infection • Severe Diarhhea suspected C.diff • ( previous Hx, NHR, Hx of antibiotics, immunosuppressed) • Septic Arthritis • Antibiotic order sets to be built into the Electronic Medical record. • Order sets to document: empiric/ therapeutic/ prophylaxis as per the CMS requirements for survey preparations.
C. Difficile guidelines • Clostridium Difficile Infection (CDI) Guidelines • Symptoms: • Mild to moderate C. difficile disease: • Watery diarrhea three or more times a day for two or more days • Mild abdominal cramping and tenderness • Severe C. difficile disease: • C. difficile causes the colon to become inflamed (colitis) or to form patches of raw tissue that can bleed or produce pus (pseudomembranous colitis). Signs and symptoms include: • Watery diarrhea 10 to 15 times a day • Abdominal cramping and pain, which may be severe • Fever • Blood or pus in the stool • Nausea • Dehydration • Loss of appetite • Weight loss • Risk Factors: • Recent antibiotic use • Age 65 years of age or older • Recent hospitalization, especially for an extended period • Nursing home or long term care facility • Recent chemotherapy use or suppressed immune system as a result of a medical condition. • Abdominal surgery or a gastrointestinal procedure • Inflammatory bowel disease or colorectal cancer • Previous C. difficile infection • Testing and Diagnosis • Testing for C. difficile or its toxins should be performed on diarrheal (unformed) stool, unless ileus due to C. difficile is suspected. • Testing for stool from asymptomatic patients is not clinical useful
C. Difficile Guidelines • 2 step method that uses a confirmatory test of C difficile antigen and C. difficile toxin A and • Enzyme Immunoassay (EIA) for C. difficile GDH antigen - highly sensitive, cannot distinguish between toxigenic and nontoxigenic strains • Enzyme Immunoassay (EIA) for C. difficile toxins A and B - sensitivity is about 75 percent; the specificity is high (up to 99 percent), relatively high false negative rate since 100 to 1000 pg of toxin must be present for the test to be positive • Polymerase Chain Reaction (PCR) testing - highly sensitive and specific, potential for false positive results • Repeat testing during the same episode is diarrhea is discouraged. • Colon examination - flexible sigmoidoscopy to detect areas of inflammation and pseudomembranes • Imaging tests - CT scan • Isolation/Infection Control • When to initiate isolation? • When to discontinue isolation? • Who can write orders for it? • Clinical Pathway for CDI • Order only 1 C. difficile assay • Discontinue anti-diarrheals and unnecessary antibiotics • Begin empiric treatment • Begin Contact precautions/isolation • Signs and Symptoms of CDI • antigen (-); toxin A/B (-)antigen (+); toxin A/B (-)antigen (+); toxin A/B (+)Tests: • Please note that only one test should be ordered. Multiple tests should be avoided. • PCR testCDI present: • Continue contact isolation (duration is until patient does not have diarrhea for at least 48 hours) • Continue treatment (duration below)CDI not present: • Discontinue CDI isolation • Provider must document in chart that the diarrheal symptoms are not associated with Clostridium Difficile Infection • Consider discontinuing CDI treatment and investigating other causes of diarrhea • Signs and Symptoms improve: • Complete course of therapy • No further toxin assaysBegin therapy for severe disease • Obtain abdominal/pelvic CT scan No improvement of diarrhea in 5 daysPositiveNegative • Testing Interpretation for CDI • EIA assay AntigenEIA Assay ToxinInterpretationRecommendationsNegativeNegativeNo C. difficile presentDiscontinue contact isolation and treatment. No repeat testing.PositivePositiveC. difficile presentContinue contact isolation therapy. No repeat testing.Positive NegativeFalse negative toxin assay or non-toxigenic C. difficilePCR test to confirm toxigenicityTreatment Recommendations for CDI • Disease SeveritySupportive Clinical DataRecommended TreatmentDurationInitial episode, mild or moderateLeukocytosis with a WBC ≤ 15,000 cells/µL and a serum creatinine level < 1.5 times the premorbid levelMetronidazole 500 mg PO every 6 hours10 to 14 daysInitial episode, severeLeukocytosis with a WBC ≥ 15,000 cells/µL and a serum creatinine level ≥ 1.5 times the premorbid levelVancomycin 125 mg PO every 6 hours or Vancomycin 250 mg PO every 6 hours 10 to 14 daysInitial episode, severe complicatedHypotension or shock, ileus, megacolonVancomycin 250 mg PO every 6 hours, plus Metronidazole 500 mg IV every 6 to 8 hours Surgical interventionFirst recurrenceSame as initial episodeSecond recurrenceVancomycin in a tapered and/or pulsed regimen
Barriers • 1. Patient Population - primarily elderly patients from Nursing Home with multiple hospital admissions • 2. Infection Type - primarily healthcare associated pneumonia required multiple empiric antibiotics which are continued for prolonged period of time • 3. Physician service - primarily voluntary physicians admitting patients, lack of access for education and awareness of AST initiatives • 4. Structure of AST program - lack of dedicated ID physician for stewardship initiatives