Strategies to reduce antibiotic consumption and inadequacy ... Bouza - O... · Strategies to reduce...

Strategies to reduce antibiotic

consumption and inadequacy and

the emergence of bacterial

resistance:

Strategies to reduce antibiotic

consumption and inadequacy and

the emergence of bacterial

resistance:resistance:

The microbiologist role

resistance:

The microbiologist role

Emilio Bouza

Porto. March. 2010

Emilio Bouza

Porto. March. 2010

Antimicrobial stewardshipAntimicrobial stewardship

Is an ongoing effort by a health care institution to optimize antimicrobial use among hospitalized patients in order to:

improve patient outcomes

Is an ongoing effort by a health care institution to optimize antimicrobial use among hospitalized patients in order to:

improve patient outcomesimprove patient outcomesensure cost-effective therapyreduce adverse sequelae of

antimicrobial use

improve patient outcomesensure cost-effective therapyreduce adverse sequelae of

antimicrobial use

MacDougall C. Clin.Microb.Rev. 2005

Antimicrobial stewardshipAntimicrobial stewardship

Antibiotic policies

Antibiotic management programs

Antibiotic control programs

Antimicrobial stewardshipAntimicrobial stewardship

A lot of opinion.

Not much scientific data

Scarce practical information on “how

to do it”

IndexIndex

Team composition

Team operation

Data provided

Team composition

Team operation

Data providedData provided

Educative measures

Active interventions

Outbreaks management

Data provided

Educative measures

Active interventions

Outbreaks management

The teamThe teamThe teamThe team

Members of the ComiteeMembers of the Comitee

Expert ServicesExpert Services

AdministrationAdministration

Target ServicesTarget Services

AdministrationAdministration

Expert Services representativesExpert Services representatives

Preventive Medicine

Microbiology

Infectious DiseasesInfectious Diseases

Intensive Care

Pharmacy

Target ServicesTarget Services

Medicine

Surgery

Obstetrics & GynecologyObstetrics & Gynecology

Pediatrics and Neonatology

Onco-Hematology

Emergency Department

AdministrationAdministration

Medical Director

Head Nurse

EngeneeringEngeneering

Administration&Economics

Main Provider

The team operationThe team operationThe team operationThe team operation

Operative systemOperative system

AssesAsses ActActAsses Act

Wilson’s systemWilson’s system

6 step procedure:

1.- To select an objective

2.- To design a method to reach it

3.- To select one or more indicators

6 step procedure:

1.- To select an objective

2.- To design a method to reach it

3.- To select one or more indicators 3.- To select one or more indicators

4.- To plan data collection

5.- To prepar a graphic display of data

6.- To make a distribution list of results

3.- To select one or more indicators

4.- To plan data collection

5.- To prepar a graphic display of data

6.- To make a distribution list of results

Main objectives Main objectives

1.- To keep the Prevalence of Nosocomial Infections under 7%

2.- To keep figures of SSI after clean surgery with prosthesis implantation under 2%.

1.- To keep the Prevalence of Nosocomial Infections under 7%

2.- To keep figures of SSI after clean surgery with prosthesis implantation under 2%.2%.

3.- To achive figures of incidence density of VAP < 10 episodes/1000 days

4.- To reduce incidence density of CR-BSI < 2 episodes/1000 days

2%.

3.- To achive figures of incidence density of VAP < 10 episodes/1000 days

4.- To reduce incidence density of CR-BSI < 2 episodes/1000 days

Main objectives Main objectives

5.- To keep <1% the proportion of patients with a bladder catheter and an Open system of drainage

6.- To reduce the incidence of episodes of MRSA bacteremia

5.- To keep <1% the proportion of patients with a bladder catheter and an Open system of drainage

6.- To reduce the incidence of episodes of MRSA bacteremiaof MRSA bacteremia

6.- To reduce the incidence of episodes of episodes of ESBL-Gram negative bacteremia of nosocomial acquisition

7.- To reduce the incidence of P. aeruginosa and other NF-GNR bacteremia

of MRSA bacteremia

6.- To reduce the incidence of episodes of episodes of ESBL-Gram negative bacteremia of nosocomial acquisition

7.- To reduce the incidence of P. aeruginosa and other NF-GNR bacteremia

Main objectives Main objectives

8.- To reduce the incidence of CDI infections of Nosocomial Origin

9.- To reduce the incidence of Candida fungemia

10.- To reduce the percent of inadequate

8.- To reduce the incidence of CDI infections of Nosocomial Origin

9.- To reduce the incidence of Candida fungemia

10.- To reduce the percent of inadequate 10.- To reduce the percent of inadequate antimicrobial use for surgical prophylaxis

11.- To reduce the therapeutic misuse of antibiotics for nosocomial infections

12.- To reduce the inadequate use of antifungal agents and the overall expenses in antifungals

10.- To reduce the percent of inadequate antimicrobial use for surgical prophylaxis

11.- To reduce the therapeutic misuse of antibiotics for nosocomial infections

12.- To reduce the inadequate use of antifungal agents and the overall expenses in antifungals

Working (Study) groupsWorking (Study) groups

Surviving Sepsis Surviving Sepsis

Severe Pneumonia Severe Pneumonia

Osteoarticular Infections Osteoarticular Infections Microb

iologyMicrob

iology

Preventive

Medicine

Preventive

Medicine

Osteoarticular Infections

Collaboration in MycologyCollaboration in Mycology

Antibacterial controlAntibacterial control

Intravascular DevicesIntravascular Devices

Microb

iologyMicrob

iology

Preventive

Medicine

Preventive

Medicine

Working (Study) groupsWorking (Study) groups

Hematology-OncologyHematology-Oncology

Solid Organ TransplantationSolid Organ Transplantation

Clostridium difficileClostridium difficile

Microb

iologyMicrob

iology

Preventive

Medicine

Preventive

Medicine

Pediatric InfectionsPediatric Infections

Surgical Site InfectionsSurgical Site Infections

Bladder catheter and UTIBladder catheter and UTI

Microb

iologyMicrob

iology

Preventive

Medicine

Preventive

Medicine

Data to be provided by different groups

Data to be provided by different groupsdifferent groupsdifferent groups

Episodes of significant bacteremiaEpisodes of significant bacteremia

113 116124,5

134,3136,5148

170

186180

167155

178

165177

160

140134

161 161 161156

131

160 159169

139148

165

140

120

140

160

180

200

113 116

0

20

40

60

80

100

120

med

-00

med

-01

med

-02

med

-03

med

-04

med

-05

med

-06

med

-07

E-2

008 F M A M J

JL A S O N D

E-0

9 F M A M J

JL A S

60

80

100

120

Microorganisms of Bacteremic EpisodesMicroorganisms of Bacteremic Episodes

0

20

40

Hong 2,5 4 5,1 4,6 4,3 4 7,7 11 11 4 10 10 10 10 4 4 9 5 12 5 7 8 4 2 8 11 10 7 4 8 4 14

Anae 4,3 6 5,6 5,3 7,8 7,6 7,2 7,6 4 5 6 6 4 7 4 6 1 8 13 5 4 9 3 3 7 5 8 8 0 6 12 3

G (-) 51 56 65 64 74 76 88 90 70 84 62 82 84 86 74 74 67 77 77 52 62 59 71 57 69 59 64 86 73 70 73 85

G(+) 69 66 70 80 71 74 86 95 114 87 89 102 80 97 85 65 76 82 81 114 105 67 104 111 109 80 84 81 79 83 74 92

m00

m01

m02

m03

m04

m05

m06

m-07

E-08

F M A M J JL A S O N DE-09

F M A M J JL A S O N D

20

25

30

35

S. aureus bacteremia and MRSAS. aureus bacteremia and MRSA

0

5

10

15

S. aureus 17 17 18 21 16 17 19 19 16 22 17 14 9 23 15 16 16 15 12 22 16 14 23 30 29 17 18 21 21 18 14 26

SAMR 7 8 6 9 6 7 6 8 6 4 4 3 3 6 3 5 5 6 3 5 5 2 3 5 10 6 5 8 6 4 7 7

m00

m01

m02

m03

m04

m05

m06

m07

E-08

F M A M J JL A S O N DE-09

F M A M J JL A S O N D

HemocultivosBacteriemia por Klebsiella spp.

HemocultivosBacteriemia por Klebsiella spp.

1010,6

9,7

13

16

12

10

16

1010

1314

13

11

15 15

12

14

16

18

6,78

10

8,6 8,69,7

9 9

67

10 1010

4

7

3

9 9 9

7 7

0

2

4

6

8

10

m00m01m02m03m04m05m06m07 E-08

F M A M J JL A S O N D E-09

F M A M J JL A S O N D

HemocultivosFungemia

HemocultivosFungemia

11 11

10 10 10 10

9

1211

10

14

10

12

14

16

2,5

3,8

5,14,6

4,2 4

7,7

4 4 45 5

78

4

2

87

4

8

4

0

2

4

6

8

m00m01m02m03m04m05m06m07 E-08

F M A M J JL A S O N D E-09

F M A M J JL A S O N D

Data provided monthly by MicrobiologyData provided monthly by Microbiology

Patients with Blood cultures requestPatients with Blood cultures requestEpisodes of nosocomial bacteremiaS. aureus BSINosocomial BLEE producing bacteremiaEpisodes of Pseudomonas bacteremiaEpisodes of fungemiaEpisodes of fungemiaEpisodes of catheter-related BSIEpisodes of BSI in I.C.U.Episodes of CDIPatients with MRSAPatients with ESBL infections (nosocomial)

Data provided monthly by MicrobiologyData provided monthly by Microbiology

LRT secretions from ICU’s with significant LRT secretions from ICU’s with significant bacteria

Positive prosthetic joint samples

Episodes of Invasive Aspergillosis

Operating Rooms with “unclean air”Operating Rooms with “unclean air”

Positive IV catheter tips. Distribution of microorganisms and Units

Bacteriuria of hospitalized patients

High-Parade Microorganisms and susceptibility

MDR microorganisms in high-risk unit

1,00

1,20

1,40

Episodios/1.000 estancias

Clostridium difficile Clostridium difficile toxigénicotoxigénicoDensidad de incidencia (interanual)Densidad de incidencia (interanual)Clostridium difficile Clostridium difficile toxigénicotoxigénicoDensidad de incidencia (interanual)Densidad de incidencia (interanual)

0,00

0,20

0,40

0,60

0,80

En98Jl

98En

99Jl

99En

00Jl

00En

01Jl

01En

02Jl

02En

03Jl

03En

04Jl

04En

05Jl

05En

06Jl

06En

07Jl

07En

08Jl

08En

09Jl

09

Episodios/1.000 estancias

HGUGM

Pacientes con aislamiento de hongos filamentosos

20

25

30CasosPacientes

0

5

10

15

20

Casos 1,25 2 3 1 2 1 3 2 2 1 1 2 4 2

Pacientes 11 14,3 21 18 16 17 16 11 9 9 7 21 14 13

Media 08

Media 09

Enero Febr. Marzo Abril Mayo Junio Julio Agos. Sept. Oct. Nov. Dic.

Casos de micosis filamentosas

MUCORMICOSIS4 (16%)

AI/ESCEDOSP1 (4%)

AI/MUCORM.1 (4%)

ESCEDOSPO.3 (12%) AI

16 (64%)

Servicios de pacientes con IFIs

10

12

1452%

5

2 21

13

20

2

4

6

8

10

Digestivo Geriatria Oncohemato Onco UVIS Otros

Microorganism Pen Oxa Lin Vanc Dapt Tig

S. aureus

Data provided monthly by Microbiology% Susceptibility

Data provided monthly by Microbiology% Susceptibility

S. aureus

C.N.S.

Enterococcus

S. pneumoniae

Microorganism Cef1 Ceftr Cefta Cipr Toba AK

E. coli

Enterobacter

Data provided monthly by Microbiology% Susceptibility

Data provided monthly by Microbiology% Susceptibility

Klebsiella

P. aeruginosa

A. baumanii

Microorganism Fluco Vori Posa Candin AmB

C. albicans

C. parapsilosis

Data provided monthly by Microbiology% Susceptibility

Data provided monthly by Microbiology% Susceptibility

C. tropicalis

C. glabrata

C. krusei

Data provided by Preventive MedicineData provided by Preventive Medicine

Surgical site infections (clean surgery)

Surgical site infections (non-clean)

Yearly Point Prevalence Study of NI

Outbreaks (solved and active)

Data provided by Pharmacy and AbxData provided by Pharmacy and Abx

Prevalence study of Antimicrobial agents

For prophylaxis

For treatment

Antibiotic misuseAntibiotic misuse

DDD’s of Antibacterials/1000 admissions

Distribution of DDD’s per Unit

Distribution per antibiotic families

Cost of buying antibacterials

Data provided by Pharmacy and AbxData provided by Pharmacy and Abx

DDD’s of antifungals

For prophylaxis

For treatment

Antibiotic misuse

DDD’s of Antifungals /1000 admissions

Distribution of DDD’s per Unit

Distribution per antifungal families

Prevalence study of bladder catheterizationPrevalence study of bladder catheterization

Catheterized patients/1000 admissions

% of bacteriuric patients

Inadequate catheterization

% Closed system

Inadequate handling of urine bag

Data provided by Surviving sepsisData provided by Surviving sepsis

Lactate determinations/1000 admissions

Evolution of sepsis alarm

Evolution of Sepsis alerts in Emergency Evolution of Sepsis alerts in Emergency

Department

Delay between antibacterial prescription

and antibacterial administration

Microbiological alerts

373

323 326

365

396374

395

346

392

318

363341

362

300

350

400

450

500

Severe Pneumonia Group (ICU’s)Days of stay and admissionsSevere Pneumonia Group (ICU’s)Days of stay and admissions

245

52 5037

57 51 58 51 5228

58 62 59 5146

0

50

100

150

200

250

300

N08

D08

E09

F09 M09 A09MY09

J09

JL09 A09

S09 O09 N09

D09

Estancias Ingresos

333343

309

359

387

356

395

332

382

311326 325

339327 325 324

345

378

352

452

312

379

301314 313

348

350

400

450

500

Severe Pneumonia Group (ICU’s)Days of mechanical ventilationSevere Pneumonia Group (ICU’s)Days of mechanical ventilation

159 157

182

209 213

189

216

245

204

142 143

105

172 177

242240

301

0

50

100

150

200

250

300

N08 D08 E09 F09 M09 A09 M09 J09 JL09 AG09 S09 oct-09 N09 D09

Días VM Días CVC Días SV

182

209 213

189

216

245

204

172 17737,03200

250

300

40

50

60

Severe Pneumonia Group (ICU’s)Incidence density of VAPSevere Pneumonia Group (ICU’s)Incidence density of VAP

159 157142 143

105

172

14

2

75 4

8

35

13 2 3 46,28

25,47

10,98

33,49

23,4721,16

37,03

12,24

24,5

7,04

20,9719,04

17,4

24,56

0

50

100

150

N08 D08 E09 F09 M09 A09 MY09 J09 JL09 A09 S09 O09 N09 D09

0

10

20

30 %

Días VM NAVM/1000d Lineal (NAVM/1000d)

Other Data provided by the Severe Pneumonia GroupOther Data provided by the Severe Pneumonia Group

% patients under MV with semirecumbent

position

% of patients with C.A.S.S.

% patients with oral hygiene with

chlorhexidine

Data provided by IV Catheter GroupData provided by IV Catheter Group

Episodes of CR-BSI/1000 days of

exposure

Implantation bundle fulfilled and signed

Maintainance bundle fulfilled and signed

356

387

359

309

352

304

10,12250

300

350

400

10

12

14

Severe Pneumonia Group (ICU’s)Incidence density of CR-BSISevere Pneumonia Group (ICU’s)Incidence density of CR-BSI

2

0 0

1

2

1

4

0

3

0

1

2

0

22,78

5,16

2,8

0

7,85

0

3,21

6,13

0

5,89

00

5,68

0

50

100

150

200

250

N08 D08 E09 F09 M09 A09 MY09 J09 JL09 A09 S09 O09 N09 D09

0

2

4

6

8

Días expos.catéter Epi/ BRC/1000d

Educative InterventionsEducative InterventionsEducative InterventionsEducative Interventions

Educative InterventionsEducative Interventions

Preventive MedicinePreventive MedicineA permanent course on Hand Hygene

Microbiology:Microbiology:Course of Treatment of Infections (yearly)

Contributions to the other courses

Internal Medicine and EmergenciesInternal Medicine and EmergenciesInfectious Disease Emergencies

Contributions to the other courses

Surviving SepsisSurviving SepsisSurviving Sepsis Principles

Management of Infective Endocarditis

Educative InterventionsEducative Interventions

Severe PneumoniaSevere PneumoniaManagement and Prevention of Nosocomial Pneumonia

Osteoarticular infectionsOsteoarticular infectionsA one day activity on the management of Osteoarticular InfectionsA one day activity on the management of Osteoarticular Infections

Collaboration in MycologyCollaboration in MycologyA course of 2 days on systemic mycosis: treatment and prevention

Intravascular DevicesIntravascular DevicesManagement of Catheter Related Infections.

Working (Study) groupsWorking (Study) groups

Solid Organ TransplantationSolid Organ TransplantationPrevention and management of Infections in SOT and Immunocompromissed patients

Pediatric InfectionsPediatric Infections

Pediatric nosocomial infectionsPediatric nosocomial infections

Surgical Site InfectionsSurgical Site InfectionsPrevention and treatment of Surgical Site Infections

Bladder catheter and UTIBladder catheter and UTIUTI: Prevention and management

Active Interventions: MicrobiologyActive Interventions: Microbiology

Early Diagnostic procedures

Selection of diagnostic techniques

Improvement in communication (telephone)

Selection of antibiotic formulary

Restriction of antibiotic information

Early Diagnostic procedures

Selection of diagnostic techniques

Improvement in communication (telephone)

Selection of antibiotic formulary

Restriction of antibiotic informationRestriction of antibiotic information

Adequacy of sepsis treatment

Computer-Assisted strategies

Telephonic antibiotic consultation

Triggering non-requested ID consultations

Restriction of antibiotic information

Adequacy of sepsis treatment

Computer-Assisted strategies

Telephonic antibiotic consultation

Triggering non-requested ID consultations

OutbreaksOutbreaksOutbreaksOutbreaks

Role in outbreaksRole in outbreaks

Microbiology:

Rapid identification of the problem

Environmental culturesEnvironmental cultures

Genotyping of microorganisms

Participation in the “Crisis cabinet”