ISHOULD DO IT, ICAN DO IT, IDO IT - STEWARDSHIP 2013 DEBRA GOFF PHARM D., FCCP CLINICAL ASSOCIATE PROFESSOR INFECTIOUS DISEASE SPECIALIST
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iShould do it, iCan do it, iDo it
Stewardship 2013
Debra Goff Pharm D., FCCP
Clinical Associate Professor
Infectious Disease Specialist
The Ohio State University Medical Center
Columbus, Ohio. USA
Outline • iShould do it review the 2012 implementation of SASSP • iCan do it review stewardship success from S Africa • iDo it Describe the bridge between OSU/S Africa
iShould do it • 2012 FIDSSA formed SAASP • Priorities were identified • Barriers to success were noted • A bridge between S. Africa and OSU was formed • Stewardship is a Global responsibility
Fleming gave warning in 1946 • “the public will demand (the drug and) … then will begin an era … of abuses. In such a case the thoughtless person playing with penicillin treatment • is morally responsible for the death of the man who finally succumbs to infection with the penicillin‐resistant organism. Fleming A. Penicillin‘s Finder Assays its Future. New York Times. June 26,1945:21.
World Health Organization
WHO director-general says antimicrobial resistance getting worse
Sept 24, 2013
“We need a strong and far-
reaching strategic plan, with
clear roles for WHO and the
many others who can help
reverse these alarming
trends,” Chan said.
“If we lose our most
effective antimicrobials, we
lose modern medicine as
we know it.”
4th World HAI Forum on Antimicrobial 70 international specialists in antimicrobial resistance • CHALLENGE: "stewardship" lacks a main outcome measure • Decrease antimicrobial resistance decreasing costs shortening length of stay educating the next generation of clinicians
Who was there?
• The role of globalization in the emergence of superbugs that
knows no borders. Dr Abdul Ghafur India
• Dr Lindsay Grayson will report on progress made since the
World Health Organization’s (WHO) 2001 Initiative.
• Drs Stephan Harbarth and Herman Goossens will chair a
session dedicated to antimicrobial stewardship and the interest
of rapid diagnostics in this approach
• The WHO’s role in infection control initiatives will be discussed
by Dr Carmem Lucia Pessoa Da Silva
• Centers for Disease Control and Prevention (CDC) with Dr
Arjun Srinivasan and the European CDC with Dr Dominique
Monnet.
Centers for Disease Control 2013
2013 CDC document
Frame the Problem
Do you use colistin?
•Create urgency Bad Bugs, No Drugs
2013 Feb Clin Inf DisInfographics http://pinterest.com/pin/287386019941460726/
iCan do it! Challenges: Few ID physicians/pharmacists, lack of funding, lack of national awareness
Early, appropriate therapy is key to survival
Survival – Patients with Septic Shock
82%
77%
70%
61%
57%
50%
43%
32%
26%
19%
9%
5%
Time to Appropriate Antimicrobial Rx following Onset of Hypotension (Hrs)
n = 2,731
Kumar et al. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit
Care Med. 2006 Jun;34(6):1589-96.Do You Know Your Hang Time?
How much time MD orders IV antibiotic
has elapsed?
RN hangs the IV antibiotic Order must get to the pharmacy
RN receives all IVs Pharmacy staff prepares the IV
antibiotic
IV antibiotic delivered to the ICUHang-Time in ICU • Netcare Sunninghill Hospital • 1400 documented interventions • Compliance increased from 59% to 85% • Effective campaign hang-time saves lives 2013 abstract Third Annual Conf SASOCP Hewitt B
Hang Time in ICU • UCT Private Academic Hospital • Weekly audits • Ensure adequate quantities on wards • Hang time of > 1 hour was reduced from 25% to 5% 2013 abstract Third Annual Conf SASOCP Smith C
“In order to preserve our existing resources, we believe that it is ethically justifiable to consider restricted use of antibiotics and punitive measures for those failing to comply.” S Afr Med J 2012;102(7):613-616
Antibiotics and outcome in S. African ICUs
Appropriate therapy
was associated with
11% mortality
Inappropriate choice
was associated with
a 27% mortality
(p=0.01)
Ref:Paruk F., Richards G., et al 2012 SAMJ 102(7)613-6The spread of carbapenem-resistant Enterobacteriaceae in
South Africa: Risk factors for acquisition and prevention
Adrian Brink, Jennifer Coetzee, Cornelis Clay, Craig Corcoran, Johan van Greune, J D
Deetlefs, Louise Nutt, Charles Feldman, Guy Richards, Patrice Nordmann, Laurent Poirel
• Cumulative antibiotic exposure is likely to be the most
important factor determining risk for developing a CRE
infection.
• The risk increases with increasing duration of
treatment.
• Suboptimal dosing may also be a contributing factor for
the development of resistance
• These strategies should be urgently implemented in all
our hospitals Ref: Brink et al. 2012 SAMJ 102;7Superbug CRE
%
The average time to
negative culture post
hospital discharge was
387 days
to clear the organism
Ref: Zimmerman et al 2013 AJIC 41;190-4Multi-drug resistant bacteria on
the rise in SA
• Increasing numbers of CRE and P. aeruginosa
are being reported in both the private and public
sectors of Western Cape, Gauteng and KwaZulu-
Natal.
• VRE have now become established in Port
Elizabeth/Uitenhage, Cape Town
• The dissemination of these organisms highlights
the difficulties in communication that arise as a
result of the lack of forums for sharing.WESTERN CAPE ACADEMIC HOSPITALS ANTIMICROBIAL RECOMMENDATIONS 2012 Groote Schuur and Tygerberg Hospitals
S. Africa Pip/tazo Resistance W. Lowman South Afr J Epidemiol Infect 2013;28(1):16-21
Action: Meeting with Health Minister
• Drs Adrian Brink and Marc Mendelson
• Goal: make antibiotic stewardship a national
priority
• Result: call a national Antibiotic
Stewardship/IPC summit
• An antibiotic stewardship programme falls within the Office for
Health Standards Compliance (OHSC) which is being
established in 2013 as part of the NHIThe new logo sends a strong message to stop and think before prescribing antimicrobials
SAASP statement
• we call upon the NDoH to:
• Make Antibiotic Stewardship a national core standard for all health care
facilities in South Africa.
• Assign leadership and management of Antibiotic Stewardship at different
levels of the healthcare service including the District Clinic Specialist Team
(DCST). Consideration should be given to allocating a clinical pharmacist
trained in AS to each DCST
• Partner with and provide administrative support to SAASP to develop a
national training programme in Antibiotic Stewardship (whilst in this regard,
clinical pharmacists training is being undertaken on a large scale by various
stakeholders)
• Develop a coordinated public health campaign around Antibiotic
Stewardship, adopting a national Antibiotic “Conservation” dayiDo it!
SOS
SOS Stewardship Ohio Style
Apps for Global Stewardship
Be part of the solution not the problem
For iPhone,
iPad
Released
June 2013
2013 Clin Inf Dis 57(8)1145-54iBook on the iPad
Infectious Diseases
There’s an App for That!
Debra Goff PharmD, FCCP
• Free on iPads for the
world of stewardship
• Use iBook author app,
search using infectious
diseases or Debra Goff
• 5 apps reviewed along
with video demonstrationBuilding a Bridge S. Africa and OSU
Mentoring Program
4 Public and Private Hospitals
• OSU stewardship program
2 week training with Clinical Pharmacists
On site visit to hospital
• Netcare Hospitals: Linksfield and Milpark
(Dr Adrian Brink and Dr. Dena van den Bergh)
• University of Cape Town Groote Schuur Hospital
(Dr Marc Mendelson)
• University of Stellenbosch Tygerberg
(Dr. Jantjie Taljaard)Future iBooks • Antibiotic Stewardship Bugs without Borders, the World Responds! • Global Stewardship Building a Bridge between OSU and S Africa
Stewardship
It’s for everyone not just ID!
Infectious
Diseases
Infection
Control
Stewardship Surgeon
OncologistStewardship: You did it! We touch the world 1 patient at a time
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