Outline of presentation. Pinyo Rattanaumpawan; Sajja Supornpun; Basic Concepts of ASP Research to Practice in ASP ASP Siriraj

Transcription

1 1 Pinyo Rattanaumpawan; MD, MSCE, PhD Division of Infectious Diseases and Tropical Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University Sajja Supornpun; BPharm, MS Department of Pharmacy, Faculty of Medicine Siriraj Hospital, Mahidol University Outline of presentation Basic Concepts of ASP Research to Practice in ASP ASP Siriraj

2 2 What is ASP? ASP is a key component of multifaceted approach to preventing emergence of antimicrobial resistance (AMR) ASP strategies 1. Education/Guidelines 2. Formulary/Restriction 3. Review and feedback 4. Computer assistance 5. Antimicrobial cycling

3 1. Education/Guidelines Procedure: Creation of guidelines for antimicrobial use Group or individual education of clinicians by educators Personnel: Antimicrobial committee to create the guidelines Educators Advantages: May alter behavior pattern Avoid loss of autonomy Disadvantage: Less effective 2. Formulary/Restriction Procedure: Restrict dispensing of targeted antibiotics to approved indications Personnel: Antimicrobial committee to create the formulary Approval personnel Advantages: Most direct control over antimicrobial use Individual educational opportunities Disadvantage: Perceived loss of autonomy Need for all-hours consultant availability 3

4 4 3. Review and feedback Procedure: Review of targeted antibiotics for appropriateness Contact prescribers with recommendation Personnel: ASP committee to create the guidelines Review personnel (usually clinical pharmacists) Advantages: Avoid loss of autonomy Individual educational opportunities Disadvantage: Less effective 4. Computer Assistance Procedure: The system will provide individual recommendation at point of care Personnel: Antimicrobial committee to create the IT system Review personnel and computer program Advantages: Provides individual recommendation Facilitates other strategies Disadvantage: Need sophisticated system Significant time and resource investment

5 5 5. Antibiotic Cycling Procedure: Scheduled rotation of antibiotic used in hospital or unit Personnel: Antimicrobial committee to create protocol Personnel to oversee adherence Advantages: May reduce resistance by changing selective pressure Disadvantage: Might not effective (difficult to ensure adherence to cycling protocol) Building The Team Hospital Administrators Infectious Diseases Specialists Infection Control Clinical Pharmacists Antimicrobial Stewardship Microbiologist OR Personnel Surgical Infection Experts/Surgeons Pulmonologist/ Intensivist

6 6 Building The Team General Practitioner Hospital Administrators Clinical Pharmacists Antimicrobial Stewardship OR Personnel ASP Endpoints Clinical and Economic outcomes Antibiotic consumption: Defined daily dose (DDD) or Day of Therapy (DOT) DDD of antibiotic-x = Total amount of antibiotic-x used WHO assigned DDD of antibiotic-x DOT of antibiotic-x = Total duration of antibiotic-x use Example - Levofloxacin WHO DDD = 500 mg/d Total amount used = 750 mgx10 day = 7500 mg DDD = 7500/500 = 15 DOTs = 10 days Polk RE. CID 2007;44:664-70

7 7 DDD vs. DOTs DDD underestimates antibiotic exposure in Patients with impaired renal function Pediatric patients Polk RE. CID 2007;44: Outline of presentation Basic Concepts of ASP Research to Practice in ASP ASP Siriraj

8 8 Update from 2016 IDSA/SHEA guideline for ASP Implementation Recommendations: Preauthorization/prospective audit and feedback Incorporate computer systems PK dosing vancomycin, aminoglycoside Alternate ceph dosing strategies to reduce cost IV-to-PO switching Guideline for Implementing an Antibiotic Stewardship Program CID 2016 Update from 2016 IDSA/SHEA guideline for ASP Implementation Recommendations (c0nt.): Shortening duration Development of stratified antibiogram to assist ASPs in developing ATB guideline for empirical therapy Selective and cascade reporting of ATB (not report all ATBs tested) Guideline for Implementing an Antibiotic Stewardship Program CID 2016

9 9 Update from 2016 IDSA/SHEA guideline for ASP Implementation Recommendations (cont.): Rapid test for viral, serial PCT, non culture based fungal marker DOTs instead of DDD Costs should be measured based on administration costs not purchasing cost Syndrome specific monitoring Guideline for Implementing an Antibiotic Stewardship Program CID 2016 Update from 2016 IDSA/SHEA guideline for ASP Implementation Against: X ONLY didactic educational materials X Antibiotic cycling Guideline for Implementing an Antibiotic Stewardship Program CID 2016

10 Pre-prescription-authorization (PPA) vs. Post-pres. Review & feedback (PPRF) A quasi-experimental, crossover trial comparing PPA and PPRF for adult inpatients at John Hopkins hospital ASP by ID-trained clinicians (based on hosp. guideline) PPA DOT PPRF Clinical Infectious Diseases 2017;64(5): Impact of a Hospital-Based Antimicrobial Management Program on Clinical and Economic Outcomes A study conducted at a tertiary care hospital ID-clinical pharmacists (AMT) vs. ID-fellows ID-specialists decision: gold standard The AMT team outperformed the ID fellows Appropriateness [87% vs. 47%; P =0.001] Cure rate [64% vs. 42%; P=0.007] Treatment failures [15% vs. 28%; P=0.03] No difference in cost saving Gross, R. et al. CID 2001;33: