Every Antimicrobial, Every Team, Every Day: Detailed Description of Antimicrobial
Stewardship Interventions at a Free-Standing Children’s Hospital
Mailing Address:
13123 E 16th Ave, B375 Aurora, CO 80045
Email Address:
[email protected]
Telephone: 720-777-5751
Amanda L. Hurst, PharmD1, Matthew Millard, PharmD1, Jason Child, PharmD1, Sarah K. Parker, MD2
Hospital Colorado Department of Pharmacy 2University of Colorado School of Medicine, Department of Pediatrics, Section of Pediatric Infectious Diseases and Epidemiology
CONCLUSIONS
• Over the 18 month study period
• Reviewed 32,761 orders on 24,929 patients
• 3,078 interventions on 1,913 patients
• Overall acceptance rate of 86%
Table 1: Interventions by Type Over Time
250
200
Interventions by Type/Subtype, by Antimicrobial, and by Team
• De-escalation of therapy was the most common intervention, followed
150
by educational interventions (Table 1)
• Vancomycin, anti-Pseudomonal β-lactams, and ceftriaxone were
most commonly implicated (Figure 1)
100
• Interventions highest on medical, intensive care, surgical, and
oncology units (Table 2)
• Acceptance rates varied from 68%-100% (Table 2)
50
Figure 1: Number of Interventions by Antimicrobial Type
• Descriptive study of interventions by the handshake
stewardship team
• Study period October 2014 – April 2016 (18 months)
• Intervention information collected (date, antimicrobial(s)
involved, types and subtypes of interventions, team
involved, and acceptance)
Type
Subtypes available
D/C or De-escalation
•
•
•
D/C of inappropriate or redundant
antimicrobial
De-escalation of broad-spectrum
antimicrobial
D/C of antimicrobial when therapy
completed
IV to PO conversion
Decrease in dose/duration
•
•
•
•
Increase in dose/duration
Escalation of empiric therapy
PO to IV conversion
ID consult recommended
Intervention Based on
Diagnostic Tests
•
•
•
Change based on culture/lab data
Drug or diagnosis mismatch
Change based on BCID or MALDI
Intervention Based on
Toxicity or Cost
•
•
Change in therapy to avoid ADR
Change to equivalent, most costeffective regimen
•
•
Prolonged
Duration/Escalation
Education
other
(n=465) 19%
Intervention based on toxicity or cost
Intervention based on diagnostic tests
Education
Prolonged duration or escalation of anitmicrobials
D/C or De-escalation of antimicrobials
vancomycin
(n=415) 17%
Table 2: Total Interventions and Interventions Accepted by Unit
1st and 2nd
generation
cephalosporins
(and nafcillin)
(n=165) 6%
antiPseudomonal
β-lactams
(n=382) 15%
fluoroquinolones
(n=182) 7%
600
The listed authors have no relevant financial relationship to
disclose, nor are there any conflicts of interest.
Apr-16
ACKNOWLEDGEMENTS
500
We would like to acknowledge the providers and
pharmacists at CHCO who welcome stewardship
interventions on a daily basis. We would also like to
acknowledge the pharmacy, microbiology, epidemiology,
and infection control departments who all support
stewardship initiatives.
200
β-lactamase
inhibitor
combos)
(n=319) 13%
DISCLOSURES
700
300
3rd generation
cephalosporins
(n=340) 14%
• Tracking designated intervention types and subtypes
assists in describing stewardship interventions over time
• Educational interventions increased over the study
period
• New Joint Commission Standards requiring
educational initiatives go into effect January 2017
• Antibiotics not commonly reviewed by most stewardship
programs were involved in a sizeable percentage of total
interventions (>10%)
• Ampicillin/ampicillin-sulbactam
• Amoxicillin/amoxicillin-clavulanate
• Macrolides
• Clindamycin
• Handshake stewardship resulted in high acceptance of
interventions
• >80% except for Pulmonary (78%) and ENT (68%)
• Other ASPs could consider expansion of PAF to all
antimicrobials to optimize decreased and optimized use
800
400
macrolides and
clindamycin
ampicillin/amoxi
(n=225) 9%
cillin (and their
Mar-16
Feb-16
Jan-16
Dec-15
Nov-15
Oct-15
Sep-15
Aug-15
Jul-15
Jun-15
May-15
Apr-15
Mar-15
Feb-15
METHODS
Jan-15
0
Dec-14
• Handshake stewardship at Children’s Hospital Colorado
(CHCO) implemented in October 2013
• Prospective-audit-and-feedback (PAF) of all
antimicrobials (MD and PharmD)
• Communication provided directly to teams during
clinical rounds (MD and PharmD)
• Though PAF is a core strategy of most antimicrobial
stewardship programs (ASPs), most review a restricted
set of antimicrobials or certain units, and most do not
interact in person with providers
• Under handshake stewardship, we tracked all
interventions and describe them by type, antimicrobial,
and team
• The goal is to inform other ASPs in identifying 1) types
of interventions to track, 2) types of antimicrobials to
monitor, and 3) teams to target
RESULTS
Nov-14
BACKGROUND
Oct-14
1Children’s
100
0
Total Interventions
Interventions Accepted