Cepheid — Conference Presentation (2009)
37 slides from Cepheid's conference presentation, 2009
Slide 1: Optimizing Antimicrobial Stewardship and Therapy Using a Rapid MRSA/SA Blood Test
Optimizing Antimicrobial Stewardship and Therapy Using a Rapid MRSA/SA Blood Test Debra A. Goff, Pharm.D., FCCP Clinical Associate Professor Infectious Diseases Specialist The Ohio State University Medical Center Columbus, Ohio
Slide 2: Outline
Outline • Impact of antimicrobial resistance (MRSA) in the hospitalized patient • Discuss the role of each antimicrobial stewardship program (ASP) team member with the rapid PCR Xpert® MRSA/SA BC test • Describe the implementation of Xpert® MRSA/SA BC (blood culture) test at OSUMC • Compare before/a
Slide 3: The Ohio State University Football Stadium
The Ohio State University Football Stadium Capacity 105,000 people
Slide 4: Impact of Antibacterial Resistance
Impact of Antibacterial Resistance • Each year an estimated 1.7 million patients in U.S. hospitals acquire an infection resulting in 100,000 deaths1 • This results in an additional $6.5 billion in health care expenditures 2 • On October 1, 2008, CMS limited reimbursement for hospital-acquired condit
Slide 5: Curbing Antibiotic Use In War on 'Superbugs'
BEn BEE BEE BE Bee Bee hee OC THE WALL STREET JOURNAL. THE INFORMED PATIENT | SEPTEMBER 3, 2008 Curbing Antibiotic Use In War on 'Superbugs' By LAURA LANDRO Hospitals are turning to a new breed of antibiotic SWAT team to win the war against "superbugs" -- the bacteria that are outmaneuvering nearly
Slide 6: Hospital Infections: Preventable and Unacceptable
Hospital Infections: Preventable and Unacceptable $2.5 million awarded by a jury in a medical malpractice suit against a heart surgeon. The patient had a pacemaker surgically implanted and developed MRSA. It was so severe that he had 15 operations, spent 84 days in the hospital, and lost his right l
Slide 7: Health-care-associated reporting laws and regulations
Figure 1. Health-care-associated reporting laws and regulations. Copyright 2008—Association for Professionals in Infection Control and Epidemiology, Inc. Last updated 06/30/2008. (BB States with study laws 1B Mandates public reporting of infection rates fa Mandates reporting only to state government
Slide 8: Impact of Antibiotic Resistance
Impact of Antibiotic Resistance Infection and Causative Increased Risk Attributable Attributable Organism of Death (OR) Length of Stay Cost ($) (days) MRSA bacteremia 1.9 2.2 6,916 MRSA surgical infection 3.4 2.6 13,901 VRE infection 2.1 6.2 12,766 Resistant Pseudomonas 3.0 5.7 11,981 infection Resi
Slide 9: Health-care Associated Infections: The Cost Impact
Health-care Associated Infections The Cost Impact Ref Kuper K. et al Am J Health-Sys Pharm 2009 66;488-94
Slide 10: Thoughts in 2009
Thoughts in 2009 • Realizing hospitals will have limited reimbursement for several infections acquired during hospitalization • A test that is easy to perform and allows rapid,early identification of MRSA/SA bacteremia should benefit patients and impact on hospital cost of care
Slide 11: Implementation Steps for real-time PCR rapid detection of MRSA/SA BC
Implementation Steps for real-time PCR rapid detection of MRSA/SA BC 1. Identify how rapid diagnostic testing could improve patient care • Identify the prevalence of MRSA at your hospital Obtain this from your own hospital antibiograms • Calculate the cost of managing MRSA/SA If you don’t have your
Slide 12: MRSA Rate and Isolates at OSUMC 1997-2007
MRSA Rate and Isolates at OSUMC 1997- 2007 80 1870 70 1670 1470 Total MRSA Isolates 60 1270 50 % MRSA 1070 40 870 30 670 20 470 10 MRSA Rate # MRSA Isolates 270 0 70 1997 2002 2003 2004 2005 2006 2007 Based on OSUMC Antibiogram
Slide 13: Implementation Steps: How well do clinicians use results?
Implementation Steps for real-time PCR rapid detection of MRSA/SA BC 2. How well do clinicians actually use the results of a new diagnostic microbiology test? Three recent studies show, we don’t do so well!
Slide 14: Do MD's Use Hospital Antibiograms?
Do MD’s Use Hospital Antibiograms? Online survey of 545 residents at a University Teaching Hospital 1% 3% •How data is 32% communicated to the medical staff is critical 64% always frequently occasionally never Mermel et al. Clin Inf Dis. 2008:46;1789.
Slide 15: Impact of mecA Testing and Intervention by ID Pharmacists
Impact of mecA Testing and Intervention by ID Pharmacists on Time to Optimal Therapy for SAB • Objective: Evaluate the impact of interventions by ID pharmacists at University of Michigan Health System, on adjustment of antimicrobial therapy on the basis of mecA gene test results. • Primary endpoint:
Slide 16: Impact of PNA FISH-generated lab data translation to bedside
Impact upon clinical outcomes of translation of PNA FISH-generated lab data from the clinical micro bench to bedside in real time • Hypothesis: Rapid detection of bloodstream infections and DELIVERY of the information to treating clinicians facilitates optimization of antimicrobial therapy and focus
Slide 17: The OSUMC implementation plan
Implementation Steps for real-time PCR rapid detection of MRSA/SA BC The OSUMC implementation plan •James Cancer Center 175 beds bone marrow transplants/oncology •Ross Heart Hospital 115 beds Heart and lung transplants/cardiac •The Ohio State University Hospital 750 beds solid organ transplant/gen m
Slide 18: OSU Antimicrobial Stewardship Program
OSU Antimicrobial Stewardship Program
Slide 19: Implementation Steps: Xpert MRSA/SA BC
Implementation Steps for real-time PCR rapid detection of MRSA/SA BC Xpert® MRSA/SA BC • Clinical microbiologist presents data to antibiotic subcommittee with recommendations to implement test • In-house validation done • ASP discusses how to communicate the availability of the new test to the medic
Slide 20: Can clinicians interpret the micro reports?
Can clinicians interpret the micro reports? Microbiology reports results consistent with FDA labeling which is MRSA/SA CoNS MSSA MRSA
Slide 21: ASP Management of S. aureus bacteremia
ASP Management of S. aureus bacteremia Pre Post Xpert MRSA/SA BC Xpert MRSA/SA BC Suspect SA Suspect SA Blood cultures drawn Blood cultures drawn Start vancomycin Start vancomycin Growth in blood culture Growth in blood culture Gram stain: gm+cocci groups Gram stain: gm+cocci groups Xpert MRSA/SA do
Slide 22: The old culture based method
The old culture based method 4 days from identification Of gram + cocci to final definitive results
Slide 23: Clinical Impact of rapid PCR GeneXpert blood culture test
Clinical Impact of rapid PCR GeneXpert® blood culture test for detection of SA/MRSA • Objective: Evaluate the clinical impact of the rapid PCR MRSA/SA blood culture test with interventions by ID pharmacists at The Ohio State University Medical Center. • Method: Evaluate the difference in time from b
Slide 24: Methods
Methods Post Group Pre Group March 10- June 30, 2009 Sept - Dec 2008 117 SA cultures standard culture 35 excluded anaerobic bottle only mixed culture 74 SA cultures 82 MRSA MSSA +BC growth gram stain 44 30 gram + cocci groups MRSA MSSA 37 45
Slide 25: Patient Characteristics
Clinical Impact of rapid PCR GeneXpert® blood culture test for detection of SA/MRSA Patient Characteristics Age Surgical Medical ICU (mean±SD) service Service Pre-Xpert 53±19 20% 30% 70% (n=30) MSSA Post-Xpert 56±17 16% 13% 87% (n=45) Pre-Xpert 60±15 34% 36% 64% (n=44) MRSA Post-Xpert 56±15 24% 11%
Slide 26: Interventions
Interventions • Micro tech made 2 phone calls 1. Micro called ID PharmD with the rapid PCR MRSA/SA BC results Mon-Fri 8-5pm 2. Micro called MD or RN with the rapid PCR MRSA/SA BC results 24/7 • ID PharmD called MD with OAT recommendations After reviewing electronic medical record for allergy history
Slide 27: Interventions by ID PharmD
Interventions by ID PharmD Reason for no intervention 4 27 •Penicillin allergy •Mixed cultures •Therapy appropriate MSSA MRSA
Slide 28: Intervention: therapy switched to Optimal Antimicrobial Therapy
Intervention therapy switched to Optimal Antimicrobial Therapy (OAT) MSSA patients switched from vancomycin P=0.004 8/30 (27%) 27/45 (60%)
Slide 29: Interventions: MRSA patients switched to daptomycin
Interventions therapy switched to Optimal Antimicrobial Therapy (OAT) MRSA patients switched from vancomycin to daptomycin 3/44 (7%) 4/37 (11%)
Slide 30: Interventions: Time (days) to OAT
Interventions Time (days) to OAT 12 The time to OAT 10 10 after time of blood 8 culture draw in mean days MSSA MSSA bacteremia 6 3.6 4.5 MRSA were 3.6 vs 2 4 2 (p=0.002) a 1.6 2 day reduction in 0 time Pre Post
Slide 31: Mean Hospital Costs during antibiotic days of therapy
Mean Hospital Costs during antibiotic days of therapy A trend toward a decrease in hospital costs during antibiotic days of therapy in the post Xpert group was observed. (p=0.29) N=75 N=81
Slide 32: Outcome
Outcome No difference in all-cause mortality was observed (27% Pre-Xpert vs 21% Post-Xpert OR=0.74; 95% CI=[0.29,1.84]).
Slide 33: Outcomes: Length of Stay
Outcomes Length of Stay (LOS) 30 24 • Mean LOS was 25 19 reduced by 6.2 days mean days 20 in the rapid PCR 15 MRSA/SA BC group. 10 (21.5 vs 15.3 p=0.07) 5 0 LOS pre post
Slide 34: Conclusions
Conclusions The rapid PCR MRSA/SA BC test decreased the time to OAT after time of blood culture draw in MSSA bacteremia from 3.6 days vs 2 days (p=0.002) a 1.6 day reduction. The rapid differentiation of MSSA and MRSA in blood cultures enables faster switch to OAT Communication by the microbiology t
Slide 35: Conclusions
Conclusions Additional benefits may be seen in the time to isolation of patients with MRSA Additional benefits may be seen in discontinuing antibiotic therapy in patients with CoNS. A collaborative effort between the ASP team can make a difference in patient outcomes and cost of care
Slide 36: The Team Approach to Improving Patient Care
The Team Approach to Improving Patient Care PharmD reviews electronic medical record, calls MD with therapy recommendation ID consult for SA bacteremia Micro tech calls PharmD Micro alerts ICP and and MD/RN patient is put in isolation Retrieves patients Monitors infection rates infection related dat
Slide 37: ASP Team
ASP Team Clinical Microbiology ID MD ID PharmD P. Pancholi PhD K. Stevenson MD, MPh K. Bauer PharmD J Balada-Llast PharmD, PhD J Mangino MD J Taylor Pharm D BCPS Micro techs D Goff PharmD FCCP Epidemiology Administration Data Manager J Mangino MD D Smeenk RPh MS J. West MSPH M Soporila MD C Tubbs Ph