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Antimicrobial Stewardship
This presentation discusses antimicrobial stewardship and the challenges of implementing stewardship programs globally. It notes the lack of infectious disease physicians and pharmacists in some countries. Effective stewardship requires a multidisciplinary team approach and overcoming barriers like lack of funding, open antibiotic access, and cultural resistance to change. The presentation highlights strategies that have worked in various settings, including technology solutions, empowering patients, identifying high-risk patients, and education programs. Measuring outcomes like reduced length of stay and improved patient outcomes can demonstrate the impact of stewardship.
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Presentation at AIFIC’ 2013, Chennai, for academic purposes.
Focus on antimicrobial stewardship as a global solution to antimicrobial resistance and MDRO.
Overview of medical centers in Columbus, Ohio including James Cancer Center, Ross Heart Hospital, and The Ohio State University Hospital.
Focus on antimicrobial stewardship as a global solution to antimicrobial resistance and MDRO.
HAIs lead to 100,000 deaths and $4.5 to 5.7 billion costs. Issues of hand contamination addressed.
Emphasizes the need for a collaborative team approach in implementing antimicrobial stewardship.
Identifies barriers in India including lack of trained personnel, funding issues, and antibiotic access.
Insights on what patients in the USA are reading about antimicrobial stewardship.
Social and technical competencies for stewardship. Importance of cultural change and external expert involvement.
Essential elements like trustworthy leadership and defined accountability needed for effective stewardship.
Identifies specific stewardship activities such as IV to PO conversion with personnel involvement.
Emphasizes education for patients and healthcare workers on MDROs and hand hygiene practices.
Discusses how to control MDRO spread and possible solutions, including technology and patient empowerment.
Field studies on hand hygiene rates before and after feedback, with significant improvement noted.
Use of black light markers in hospitals to raise awareness of cleanliness and hygiene.
Discusses how to control MDRO spread and possible solutions, including technology and patient empowerment.
Examines challenges and implementations in South Africa, including education and communication efforts.
Positive outcomes from various global stewardship programs in improving antibiotic use and infection management.
Clinical outcome measures demonstrate reduction in length of stay and inappropriate antibiotic use.
List of ASP certification programs and free educational resources available for global audience.
Encourages immediate action, collaboration, and education to ensure effective antimicrobial stewardship.
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- 1. This presentation waspresented at Apollo International Forum on Infection Control (AIFIC’ 2013), Chennai The presentation is solely meant for Academic purpose
- 2. Antimicrobial Stewardship Different Challengesneed Different Solutions
- 3.
- 4. The Ohio StateUniversity 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: AGlobal 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 teamapproach
- 9. Challenges and Barriersin India • Lack of ID trained physicians and pharmacists • Lack of funding • Open access to antibiotics • Generics
- 10. What are USApatient’s reading? Ref: Wall Street Journal January 2013
- 11. What works WhatDoesn’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 forChange • 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: Definethe 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 InfectionPrevention 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 canstewardship control the spread of MDRO in your hospital?
- 18. (X Represents VRECulture 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 Indiaworking 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 onLED 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 ResourceHospitals 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 Managementof Infections : Beyond the Costs of Antimicrobials Ref: Goff D. et al. Inf Dis Special Ed. 2012 15:35-46
- 30. Antimicrobial Stewardship Managementof 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: Technologyand 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 canyou 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
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