1. Impact of a Pharmacist-Led
Antimicrobial Stewardship Program
Using Clinical Decision Support
Nathan Peterson, Pharm.D.
npeterson1@stez.org
CHI - St. Elizabeth
Lincoln, Nebraska
2. DISCLOSURE
I have no actual or potential
conflict of interest in relation to
this program/presentation
I have no actual or potential conflict
of interest in relation to this
program/presentation
3. Outline
• Introduction
– Catholic Health Initiatives- St. Elizabeth
– Why antimicrobial stewardship?
• Objectives
– Cost savings
– Improved antibiotic use
• Methodology
– Clinical Decision Support
• Results
– Cost savings
– Clinical pathway optimization
– Success stories
• Discussion
• Conclusion
4. Introduction
• Catholic Health Initiatives
– 105 hospitals
– 4 academic medical centers
– 19 states
– 30 critical access hospitals
• St. Elizabeth
– 260 bed community hospital
– Medical, Pharmacy, and Nursing
students from University of
Nebraska and Creighton
University
5. Antimicrobial Stewardship
• Centers for Disease Control and
Prevention (CDC):
– 3/2014; Published Core Elements of Hospital
Antibiotic Stewardship Programs(ASPs)
• Leadership Commitment
• Accountability
• Drug Expertise
• Action
• Tracking
• Reporting
• Education
• President Obama:
– 9/2014; Presidential Order mandating Task
Force and 5-Year Plan for combating antibiotic
resistance
6. Antimicrobial Stewardship
• Centers for Medicare and Medicaid Services(CMS):
– 12/2014; Updated checklist for infection control in hospitals
1.c.9 The hospital has written policies and procedures whose purpose is to
improve antibiotic use (stewardship).
1.c.10 The hospital has designated a leader (e.g., physician, pharmacist, etc.)
responsible for antibiotic stewardship outcomes.
1.c.11 Policy and procedures require practitioners to document an indication,
dose, and duration for all antibiotics.
1.c.12 The hospital has a formal procedure for all practitioners to review
antibiotics prescribed after 48 hours (e.g., antibiotic time out).
1.c.13 The hospital monitors antibiotic use (consumption) at the unit and/or
hospital level.
7. Background
• Pre - ASP Operations
– Decentralized pharmacists cover Critical Care, Progressive
Care, Medical, Oncology, and Burn Units
– Pharmacokinetic Services by Pharmacy for select antibiotics
– Infection Control Committee
– Infectious Disease Physicians not employees of the hospital
– contract with provider group
– Verigene
• Rapid detection of G+ and G- blood stream infections
• Pharmacy occasionally called first; dependent on
microbiologist discretion
– Yearly antibiogram
8. Pharmacist-Led Antimicrobial
Stewardship Program
• Recruit Committee – monthly meetings
– ID Physician, 2 Internal Medicine Physicians, Infection
Control, Microbiology, Chief Medical Officer
– Pharmacy Clinical Coordinator attended meetings to assist in
the handoff after the pharmacist completed residency
• Identify Goals
– Cost reduction, clinical pathway optimization, success stories
• Process Implementation
– Clinical Decision Support
– Quality and quantity metric development
– Provider education
9. Pharmacist-Led Antimicrobial
Stewardship Program
What is Clinical Decision Support(CDS)?
“CDS systems link health observations with health knowledge to influence
health choices by clinicians.” - Robert Hayward, Center for Health Excellence
Software that applies rules (e.g. if-then statements) to patient data.
-Computerized alerts and reminders for providers
-Clinical guidelines
-Condition-specific order sets
-Patient data reports and summaries
-Documentation templates (interventions, etc.)
TheradocTM
10. ASP Pharmacist using Theradoc
Intervention period
• Pharmacy resident spent 1 to 3 hours/day for three months using
a Clinical Decision Support (CDS) System report tailored to
Antimicrobial Stewardship
– Process accelerated as pharmacist and hospital physicians grew familiar with
process
• Pharmacy resident made interventions to providers based on daily
report via face to face conversation or phone/pager
• The report was broken up by unit following the intervention
period for clinical pharmacists to use
• Interventions during the 3 month period will be compared to
baseline
11. ASP Pharmacist using Theradoc
Intervention period
Criteria that prompted alert:
-Antibiotic level, new
-Relevant culture: blood,
respiratory
-Therapeutic Antibiotic
Monitoring;
-drug-bug mismatch
-inadequate/no coverage
-overlapping therapy
-broad spec. de-escalation
-no positive cultures (72 hrs)
-redundant therapy
-IV to PO switch – anti-infectives
TIME INTENSIVE STEP
14. • Pharmacist documents all interventions
• Cost savings assigned by Catholic Health Initiatives
• Cost savings comparison of pharmacist interventions before and after ASP
Pharmacist implementation
15. Pre-ASP (Monthly Ave) ASP (Monthly Ave)
Duplicate Therapy 3.25 9.3
Narrow Spectrum 6.5 19.3
No ABX Coverage 0.7 10.3
No Indication 2 16
Prolonged Duration 2.8 36.6
Drug Optimization 0.5 15.6
Total Theradoc Antibiotic
Stewardship Interventions 15.8/month 107.3/month
Vancomycin Consult 156.8 229
IV to Oral ABX 2.3 15
ABX Dose Adjust by Pharmacy 55.8 84
Non-Theradoc ABX
Interventions 214.9/month 328/month
Total Antibiotic
Interventions 230.7/month 435.1/month
17. Goals
-Cost savings
-Clinical pathway optimization
-Success stories
Cost savings (soft) from improved antibiotic use before ASP
Pharmacist: $23,336/month
Cost savings (soft) from improved antibiotic use with ASP Pharmacist:
$40,110/month
Worth noting;
-Self reported
-Costs are based on best available literature
-Length of stay and ABX $$/Patient Day data is pending
18. Results
-Cost savings
-Clinical pathway optimization
-Success stories
Infectious Disease Physician suspected we were poorly
treating empiric Urinary Tract Infection (UTI)
What could a stewardship pharmacist do?
19. MS-DRG Custom
Groups (ICD-9)
Anti-Infective % Use Quantity/Resource Case
Urinary Tract
Infection
LEVOFLOXACIN 64.76% 2.65
Urinary Tract
Infection
PIPERACILLIN/TAZO 32.15% 3.29
Urinary Tract
Infection
CEFTRIAXONE 28.57% 0.70
Urinary Tract
Infection
VANCOMYCIN 11.90% 3.00
Urinary Tract
Infection
CEFAZOLIN 5.12% 5.88
Urinary Tract
Infection
CIPROFLOXACIN 4.76% 1.38
Urinary Tract
Infection
CEPHALEXIN 3.90% 1.33
Urinary Tract
Infection
CEFEPIME 3.57% 2.67
Presented at December Meeting;
Baseline data (3 month average) from PremierTM
20. Per Johns Hopkins Antibiotic Guide*:
• Empiric Inpatient Treatment for Acute Uncomplicated Cystitis
– “Fluoroquinolones are no longer considered first line treatment and should be
reserved for special situations such as allergy or intolerance to other agents”
• Empiric Inpatient Treatment for Acute Uncomplicated
Pyelonephritis
– “Use local antibiotic susceptibility data to guide initial empiric therapy”
Ciprofloxacin 400 mg IV q12h (if local fluoroquinolone resistance rates < 10%)
Levofloxacin 500 mg IV once daily (if local fluoroquinolone resistance rates <10%)
• Complicated
– “Fluoroquinolones (FQ) are reasonable empiric choices if patient has not
received an FQ in recent past, is not from a long-term care facility, and FQ
resistance is low.”
*Guide preferred by internal medicine service
21. % Urine
Isolates
Sulfamethoxazole
/ TrimethoprimNitrofurantoin Cephalexin Levofloxacin
E Coli 58% 76% 98% 92% 76%
Klebsiella 12% 94% 57% 98% 98%
Enterococcus
faecalis 8% NI 100% NI 63%
Proteus 7% 74% 74% 84% 70%
Pseudomonas 5% NI NI NI 72%
Citrobacter 4% 75% NI NI 88%
MSSA 3% 100% 100% 100% 66%
MRSA 2% 100% 100% 0% 16%
Hospital Urine Antibiogram minus Emergency Department*
*Emergency Department urine E. Coli
susceptibility to Levofloxacin: 86%
** NI = Not indicated
22. Situation: We regularly use a fluoroquinolone for UTI treatment
despite local resistance rates
24. 64%
71%
75%
17%
14%
11%
October November December January February March
Levofloxacin usage for UTI
% of UTI
cases
“UTI” Stewardship Meeting; December 16th
Result: Levofloxacin usage for UTI decreased
25. Results
-Cost savings
-Clinical pathway optimization
-Success stories
KJ admitted for Sepsis (unknown source-
respiratory?) at 0115
• From LTC -> admitted to critical care unit(CCU)
• Medical Resident empirically selected Piperacillin-
Tazobactam, Vancomycin, and Levofloxacin
• ESBL Klebsiella
– Microbiology left message with nurse at 0430
• Alerted via Theradoc – seen in morning review @ 0800
– Needed carbapenam – contacted attending MD
• Pt. switched by 0830
26. Clinical Decision Support (cont’d)
Other functionalities of Clinical Decision Support that an ASP Pharmacist could use
• Patient flags
• Antibiogram
• Estimated doses for antibiotics
• Frequency * number of days
• 741 doses of levofloxacin during December vs. 624 during
February
(~5 minutes to run this report)
27. Obstacles
• Non-residency/infectious disease trained pharmacist using unfamiliar
software to make infectious disease interventions
– Providers not always receptive
• Initial Theradoc reports took entire day to sift through
– No expert on site
• Data not readily available (usage, etc.)
• Wide variation on what antimicrobial stewardship looks like across and
within academic and non-academic medical centers
– Differing metrics, process, medication use systems
Pharmacist-led Antimicrobial Stewardship
Using Clinical Decision Support
28. Pharmacist-led Antimicrobial Stewardship
Using Clinical Decision Support
Conclusions
• A pharmacist can lead an antimicrobial stewardship
program at a 260-bed community hospital
• Clinical Decision Support(CDS) can identify
intervention opportunities for pharmacists with
little/no specialty training
• Minimal daily activity on CDS alerts is financially
lucrative and benefits patients and institutions
29. Pharmacist-led Antimicrobial Stewardship
Using Clinical Decision Support
Future
• Skin/soft tissue order set
• CAP/HCAP order set
• Provider eduction
• Reporting
– ABX $/1000 patient days
– Length of stay for sepsis, pneumonia
– Monthly reports of antibiotic usage for sepsis, pneumonia, and UTI
• FTE Request submitted using stewardship and intervention data
– Approved by position control and facility
