ruola della antimicrobial stewardship cdi.ppt [modalità ... · strategies for controlling...

Nicola Petrosillo

Dipartimento Clinico e di Ricerca in Malattie InfettiveIstituto Nazionale per le Malattie Infettive «Lazzaro

Spallanzani”, IRCCS, Roma

Competing interests disclosure

• Honorary as speaker for Astellas, MSD, Pfizer, Novartis, B&D, Gilead, GSK, Johnson & Johnson, Angelini, Zambon

• Honorary as member of scientific board for Pfizer, MSD, Astellas, Novartis, B&D.

Cassini A et al.

Estimate of 2,609,911 new cases of HAI occurring every year in EU/EEA

91,130 deathsfor the sixHAIs

5 Boeing 787s crashing per weekat least 1/2 of the deaths attributable to HAI due to the 7 most common MDRB

Background

� Threats of MDR organisms and public health emergencies have exposed the need for more robust antimicrobial stewardship and for collaboration in the emergency preparedness.

� There is a need for coordinated efforts to effectively manage this «new deal».

� However, financial pressures are likely to compete with the expanding roles and expectations of physician-epidemiologists in IPC.

What is antimicrobial stewardship?

• A strategy, a coherent set of actions designed to use antimicrobial responsibly.

• Responsible use: it should be defined and translated into context- and time-specific actions

Dyar OJ et al. Clin Microb Infection 2017 on press

Dyar OJ et al. Clin Microb Infection 2017 on press

Dyar OJ et al. Clin Microb

Infection 2017 on press

Dyar OJ et al. Clin Microb Infection 2017 on press

Antibiotic stewardship: does it work in hospital practice?

Marlies EJL et al. Clin Microb Infection 2017

Antibiotic stewardship: does it work in hospital practice?

Marlies EJL et al. Clin Microb Infection 2017

Davey P et al.

Davey P et al.

Outcomes and Metrics for Antimicrobial Stewardship: Survey of Physicians and Pharmacists.

Bumpass JB et al, Clin Infect Dis 2014;59:S108–11

Respondents’ Opinion

In March 2012, a 55-question online survey was e-mailed to 94 physicians or pharmacists in acute care hospitals in the United States. Response rate was around 52%.

Beardsley JR et al. Infect Control Hosp Epidemiol 2012;33:398-400

Strategies for controlling transmission of multidrug-resistant (MDR) pathogens in the intensive

care unit (ICU)

• Reduce selection pressures

– Improved antimicrobial (including disinfectants?) stewardship

– Ensure balancing measures are also considered

• Prevent spread (targeted or vertical strategies)

– Screening strategies

– Improve infection control e.g. hand hygiene, isolation measures

• Consider decolonisation (Horizontal strategies)

Reducing the reservoir and perhaps increasing colonisation resistance?

The marriage between ASP and IPC

Kawamura H et al. Am J Infect Control 2016; 44: 210-4

•Contact precautions and antimicrobial stewardship are effective in preventing nosocomial MRSA infections.

•Before-after study� implementation of a bundle approach consisting of MRSA active surveillance, contact precautions for MRSA positive patients, and CFZ based AMP stewardship

Kawamura H et al. Am J Infect Control 2016; 44: 210-4

Kawamura H et al. Am J Infect Control 2016; 44: 210-4

Frenette C et al. Am J Infect Control 2016; 44: 977-82

The intervention consisted of

•Antimicrobial stewardship•Hospital staff education•Active surveillance cultures•Contact precautions•Environmental cleaning•Disinfection enforcement•Hand hygiene promotion

Viale P et al. Clin Microbiol Infect 2014

Pulcini C et al. Clin Microbiol Infect 2014; 20: 963-72

• Review of 31 studies� 7 RCTs, before/after

controlled studies or before/after uncontrolled styudies with interrupted-time-series analysis.

• IDS intervention was associated with a significant improvemente on the appropriateness of antibiotic prescribing as compared with prescriptions without any IDS input.

Association of Evidence-Based Care Processes With Mortality in Staphylococcus aureus Bacteremia at

Veterans Health Administration Hospitals, 2003-2014

Goto M et al. JAMA Intern Med 2017; 177(10): 1489-1497

Association of Evidence-Based Care Processes With Mortality in Staphylococcus aureus Bacteremia at

Veterans Health Administration Hospitals, 2003-2014

Goto M et al. JAMA Intern Med 2017; 177(10): 1489-1497

Association of Evidence-Based Care Processes With Mortality in Staphylococcus aureus Bacteremia at

Veterans Health Administration Hospitals, 2003-2014

Goto M et al. JAMA Intern Med 2017; 177(10): 1489-1497

Tagashira Y et al. Am J Infect Control 2016;44(6):708-10

McQuillen DP et al. J Infect Dis 2017;216(suppl_5):S588-S593

McQuillen DP et al. J Infect Dis 2017;216(suppl_5):S588-S593

McQuillen DP et al. J Infect Dis 2017;216(suppl_5):S588-S593

Tedeschi S et al. Infect Control Hosp Epidemiol 2017;38(1):76-82.

Tedeschi S et al. Infect Control Hosp Epidemiol 2017;38(1):76-82.

Cataldo AM et al. Expert Rev Antiinfect Ther 2017

Effect of FQ ASP on CDI incidence

Dia-gnosticStewardship

Infection PreventionStewardship

Thera-pyAntimicrobial Stewardship (A-Teams)

From competence to meta-competence

ID-doctor

Clin. Microbiol.ABS

Moleculair Medisch Microbioloog

Infection ControlPractitioner

Clin. Microbiol- infection prevention

Pharmacist

PHS

Intensivist

Dik et al. 2015 Future MicrobiologyCourtesy Prof. A

Friedrich