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¤ none …but

Ihadnothingtodowithwhathappenedtomylast

Pro-Condebateoponent

¤ AMS-whatisitabout¤ WhyisAgneswrong¤ Whyisitallaboutcosts

AnongoingefforttoopDmizeanDmicrobialuseamonghospitalizedpaDentsinorderto:

¤ ImprovepaDentoutcomes

¤ Ensurecost-effecDvetherapy

¤ ReduceadversesequelaeofanDmicrobialuse(oneofwhichisanDmicrobialresistance)

MacDougal,ClinMicrobiolRev,2005,18:638-656

¤  Consults-‘auditandfeedback’² ReserveanDbioDcs² Risk-paDents

¤  RestricDngchoices² AnDbioDcguideline(adjustedCMreportsandCPdispensing)

¤  Guidelinedevelopment² CAP² UTI

¤  ProjectstoimproveanDmicrobialuse² Switchprogram,5Sprotocol

¤  EducaDon

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¤ Start:wrongindicaDon,notaccordingtoguideline

¤ Switchivtooralnotdonewhenpossible

¤ Streamlining/adjustmentaccordingtosuscepDbilitynotdone

¤ Safety–disregardinginteracDons

¤ Stop–unneededconDnuaDon

Let’sstartthePro-Condiscussionon:

vs

Resistance Money!

…andsomehelpwithresistance

…havetosaythatbutofcourseit’s

money

Resistance Cochranereview

¤ ‘Interven:onstoimprovean:bio:cprescribinginhospitalsaresuccesfulandcanhelptoreducemicrobiologicalresistance’

¤ 3controlledstudieswithregardtoresistance:

² deMan2000,Lancet(restrictedtoNICU)² Singh2000AJRCC(automaDcstopofAB)² Toltzis2002Pediatrics(cycling)

Brown,2009,Cochranelibrary

Obviouslynot“reduce”,butpreventsomeemergence

¤ InspiteoftheknownassociaDonbetweenanDmicrobialuseandresistance,assumingthatanimprovementinmicrobio-logicaloutcomesfromstudiesthatonlydemonstrateareducDoninanDmicrobialusageishazardous.

HAZARDOUS CONCLUSIONS

Thereareother-probablyevenstronger–factorswithimpactonresistanceratesthanchangesinabsolutequanDDesofanDmicrobialdruguse:¤ DifferencesinpotenDalforselecDonofresistancebetweenanDmicrobials

¤ ImpactofduraDonoftherapyanddosagechanges

¤ Seculartrendsinresistance¤ CultureandliDgaDon,…

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Linearleast-squaresregressionofchangesinfluoroquinoloneuseonthechangesinproporDonoffluoroquinolone-resistantP.aeruginosain19hospitalsbetween2000and2003

Macdougall&PolkClinMicrobiolReview2005

•  Mosthospitalsincreasedquinoloneusebutonlyonehadamarkedincreaseinratesofresistance(squaredmarker).

Macdougall&PolkClinMicrobiolReview2005

Eighthospitalsdecreasedfluoroquinoloneuse,butinonlyonehadanimportantdeclineinresistance(circledmarker)

Macdougall&PolkClinMicrobiolReview2005

TheseoutlyingobservaDonsmaybemorelikelytobepublishedandwouldexaggeratethemodestrelaDonshipbetweenchanges

inuseandresistancenotedacrossallhospitals.Macdougall&PolkClinMicrobiolReview2005

¤ StudiesoftheimplementaDonofanDmicrobialstewardshipanditseffectsonresistanceareextremelydifficulttocontrolandareusuallyobservaDonal.

¤ AsystemaDcreviewoftheliteratureahemptedtoidenDfy“rigorousevaluaDons”ofintervenDonstoimprovehospitalprescribingofanDmicrobialdrugs.

¤ Ofthe16studiesthatmetcriteriaforinclusion,only4providedstrongevidencethatchangesinprescribinganDmicrobialdrugstohospitalinpaDentscandecreaseanDmicrobialresistance.

¤ FourstudieswerenegaDve,andthe8remainingstudieswerecitedashavingflaweddesigns,allowingforalternaDveexplanaDonsfortheoutcome.

DaveyPetal.EmergInfectDis.2006Feb;12(2):211-6.

Reducing resistance

Saving Money

Sorry,wrongpicture

Hmm… at least it’s not increasing resistance

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Reducing resistance

Saving Money

Obviously the organizers let me go first for a reason: They know that this is the

“pro” statement

Gougleditandfoundnothingaboutsaving

money!

ThedataIhaveseenarebiasedorlies

Notonesitemen:oned“An:microbialStewardship”

¤ yes,theremightevenbesome(verylihle)biasinstudiesshowingcost-savings…

AgnesAndreas

¤ Sure,weneededthemforourbusinesscase*tocreatetheA-teaminourhospital

“businesscaseinmedicine”=awellthoughtofandnon-detectablesumofliesandassumpDonstobeabletofinancewhatwebelieveisneededforthesafetyofourpaDents

¤ Sure,weneededthemforourbusinesscase*tocreatetheA-teaminourhospital

¤ SincethefundingofmanyanDmicrobialstewardshipprogramsisconDngentupondemonstraDonofcost-effecDvenessprogramsthatdonotachieveposiDveresultsmaybedisconDnued.

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¤ PaDentsreceivingoneof10targetanDmicrobialsforgreaterthan3dayswererandomizedtotheintervenDonarmortothestandardofcare.

¤  TheintervenDonconsistedofahavingaclinicalpharmacistandinfecDousdiseasesfellowreviewthemedicalrecordsofpaDentsreceivingthetargetanDmicrobials.IftherewasagreementonaneedtoopDmizeanDmicrobialtherapy(changingorstoppingtherapy,switchingtooralregimen,oranalternaDvedosage),anonpermanentchartnotewaswrihen;85%ofsuggesDonswereimplemented.

¤  Therewasnosignificantdifferenceinclinicalormicrobiolog-icaloutcomesbetweenthegroups,buttotalanDmicrobialcostsweresignificantlylowerintheintervenDonarm;yearlysavingswereesDmatedat$390,000

Fraseretal.Arch.Intern.Med1997;157:1689–1694

¤  275-bedcommunityhospitalrandomizedpaDentsreceivingpotenDallyinappropriateanDmicrobialstostandardcareortohaveamulDdisciplinaryteamprovidesuggesDonsfortherapy(67).

¤  Eighty-ninepercentofsuggesDonsprovidedintheintervenDonarmwereaccepted.

¤  Themedianlengthofstaywasshorterby3daysintheintervenDonarmthanthecontrolarm,andanoverallcostreduc:onof$2,642perintervenDonwasesDmated.

¤ Otherclinicalandmicrobiologicoutcomesweresimilarbetweenthetwogroups.

Gumsetal.Pharmacotherapy1999;19:1369

¤ RandomizedinpaDentclinicalservicesassigningtotheintervenDonarmandtothecontrolarm.

¤ AllordersforlevofloxacinorcerazidimeintheintervenDongroupwerereviewed.Ifanorderwasnotincompliancewiththeguidelines,amemberoftheA-teamcontactedtheprescribertosuggestalternaDvetherapy.

¤ TheduraDonofinappropriatetherapyofthetargetanDmicrobialswasreducedbyapproximately40%intheintervenDongroup,whileclinicaloutcomesweresimilarbetweenthegroups.

Solomonetal.ArchInternMed2001;161:1897

¤  Directcostsavingsofapproximately$8,000couldbeahributedtotheseintervenDonsalone,butgreatersavingsduetoreducedtoxicity,superinfecDons,anddevelopmentofresistancearelikelyaswell.²  Schentagetal

¤  FeweranDmicrobialswereused,themeancostofanDmicrobialsdecreased,feweranDmicrobial-relatedadversedrugeventsoccurred,andfewerpaDentsweretreatedwithadrugtowhichtheirinfecDngorganismwasnotsuscepDble.²  LaGer-DaySaintsHospitalinUtah

¤  Studieshaveshownjoint,infecDous-pharmacyprogramsformanaginganDmicrobialprogramsproducesignificantbenefitsintermsofbothqualityofcareandcosteffecDveness.²  SHEA0nline

hhp://www.cdc.gov/getsmart/healthcare/evidence/asp-int-costs.html

ConDnuesfor7pages

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PhamD

ClinMicro/ID

ICT

¤ Control/restricteduseofreserve-anDbioDcs¤ SelectandmeasurelocalindicatorsforadequateanDmicrobialuse

¤ Standardizeempirictreatmentandenhance/fosteriv-oralswitch.

¤ EducaDonandtrainingwithregardtoanDmicrobialuse

¤ DefineallpaDentscategoriesthatneedbed-sideIDconsultaDon

¤ Real-Dmesurveillance(includingfeedback)oflocalresistancetrends

¤ all-causemortality

¤ infecDon-relatedmortality

¤ duraDonofhospitalizaDon

¤ ratesofreadmission

Whatwouldyouchoosetotakehome?Whyevendebate!

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…thusitmutbeaboutthefirst$48million!

Coverslightlymodified

Reducing Resistance

(development)

Money saved to invest in:

•  A-team •  Patient safety •  Infection Control

Reducing resistance

Saving Money

It’snotonlyaboutsavingmoneyand(partly)aboutreducingresistance,it’smainlyaboutadequate

andopDmalAB-treatment

Antimicrobial Stewardship