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2/17/2012
1
Antimicrobial Stewardship at
Yakima Valley Memorial Hospital
Gregory Matsuura, PharmD, BCPS
Antibiotic Review Team Coordinator
Yakima Valley Memorial Hospital
• 225 bed acute care community hospital
• Community & hospitalist providers
• 3 independent ID specialists
• AMS Team:
– 0.5 FTE pharmacist (AMS/clinical informatics)
– ≈1 hour/week ID physician
• Infection control
• Microbiology
• Clinical Floor pharmacists (5 teams)
2/17/2012
2
If At First You Don't
Succeed, Try, Try
Again…
A bit of history
• 1999 start of antibiotic review team (ART)
– Interested staff pharmacists + ID physician
– Wide variation of interest/skill set
• 2001 Pharmacy residency project
– staff pharmacists + ID physician + pharm resident
– Wide variation of interest/skill set
• 2002-2006
– PRN stewardship
• 2007- present
– Building up interest/impact
2/17/2012
3
Clinical floor
pharmacist
Infectious
diseases
physician
Stewardship
Coordinator
Microbiology
Infection control
Development of computerized
resources (shoestring budget)
2004Year 2006 2008 2010 2012
Search by drug
mining tool
Culture results;
renal fx added
Service Flags
added
EMR bug drug
Bar code
admin Abx
use data
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4
PDF report of patients on Abxtherapy, “Follow-up” notes by pharmacists
EMR reviewed → Additional sources (RNs, Floor pharmacists, Micro lab)
Discussion with ID physician
Direct case discussion with physician
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5
Targeted review
• Patients with initial diagnosis-therapy
mismatch
• Isolate resistant/not covered by current abx
• Potential IV – PO switch
• Broad spectrum abx >3 days
• Duration >7 days
• Targeted antimicrobials
Antimicrobials of interest
Targeted - Unrestricted Restricted
Piperacillin-Tazobactam Linezolid
Cefepime Daptomycin
Vancomycin Tigecycline
Imipenem
Aztreonam
3rd generation cephalosporins
Antifungals
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6
Documented Antibiotic Review Team
Interventions
• 1/1/2010-12/31/11 (n=645)
– Streamline/de-escalate coverage 27% (n=174)
– Dosing change 29.7% (n=191)
– Antibiotic mis-match 13% (n=84)
– IV to PO 10.2% (n=66)
A minor example: Aztreonam
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0
4.5
5.0
2008 2009 2010 2011
DDD/1000
Aztreonam
DOT/1000
Aztreonam
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Target antibiotic example: Pip-Tazo
DDD/
1000 pt days
DOT/
1000 pt days
2009 75.6 105.1
2010 73.4 98.6
2011 74.8 96.2
Building Drug-bug system from
(almost) scratch
• Alerts generated in real time
– Triggered by updates in micro reports only
• Not able to scale to clinical relevance
– Needs clinical review
• Needs preliminary pathogen descriptions
trigger
– Fungus
– “Non-lactose fermenter”
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Antibiotic Stewardship and CDI
• Continued to limit broad spectrum abx
• All cases of nosocomial CDI
– Reviewed by infection control
– Reviewed by stewardship team for trends/
association
• Trend towards ↓ nosocomial abx CDI from 2009
– Low rate prevents meaningful cause-effect
• Association of PPI use and CDI?
Future steps
• Improving Drug-bug match alert system
• Improve feedback to prescribing house-staff
– Increased patient proportion seen by hospitalists
• Antibiotic use data for March meeting
– Implementation of CPOE
• Electronic data available at the provider level
• Bar coding medication record (BCMA)
– Monthly Clinical Vignette with FP inpatient service
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9
AMS experience at YVMH
• It’s a team approach– Floor pharmacists are an extension of the service
• No centralized method of contacting physicians
– Coordination with other departments• Infection control
• Microbiology
• Information is key– Prospective data mining is invaluable
– Knowing more faster
• Drug-bug match alert system
• Further evaluate potential 3rd party vendor systems
Acknowledgements
• Infectious diseases/epidemiology – Neil Barg
• All the YVMH clinical pharmacists– Angela Stewart (Assist Mgr Adv Pharmacy Services)
• Microbiology– Maria Clark
• Infection Control – Jaala Langley
• VP Patient Care Services– Sandy Dahl